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back to article NHS blames computer error for transplant fouls

The NHS Blood and Transfusion service has apologised for a computer error which meant that some people had organs removed incorrectly, or presumably not removed, because their preferences were wrongly recorded in the database. The mistake affects 800,000 people who had their transplant wishes wrongly imported from the DVLA. The …

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FAIL

Technical error?

Given the info on the case here, seems to me more likely to be a case of PEBKAC.

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FAIL

Please Repeat after me

There are NO SUCH THING as computer errors, just human mistakes.

Computers are incredibly dumb, they do EXACTLY as they are told.

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WTF?

Act of GOD

I find it interesting how many people claim there is no such thing as computer errors and immediately blame humans.

If a computer at my home is struck by a meteor while I am at work, so that it fails to download the TV shows I had programmed it to download, is this then a human error?

How about if a much smaller ionizing particle changes the state of a single bit in the list of shows to download, so that that item in the list become meaningless?

Is this the fault of me or the programmers since there should have been stronger error correction? how many bits error correction is enough?

Maybe it is the word "error" that triggers this type of comment. Does use of the word "error" only relate to conscious beings/processes?

The claim that all machine/computer errors are human errors assumes that the humans in question are all-knowing - all-powerful beings, that could have foreseen any and all situations that appear and have invented a solution for them.

So what so we need Gods for then?

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Go

Incorrect analogy

When was the last time you saw a meteor or ionzing particle affect any computer that wasn't in space? When was the last time you saw someone make a mistake?

Quod erat demonstrandum.

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Ridiculous Analogies

Sorry Claus but your analogies are ridiculous.

Firstly, if a meteor strikes and takes down a computer then that is not something that can be planned for by either the computer, the programmer or the user (the odds being so extremely low!). And i strongly doubt anyone would be blaming that on a computer error or a user error. The blame may go to the users for not having a good enough disaster recovery plan to regain the lost information in a quick and orderly fashion, but the strike itself would not be blamed on a computer error.

Secondly, within the earths atmosphere ionising particles are not a risk to computers, however, in space this is a definte risk and it is one that is taken into account on every satellite that is currently flying above this big blue sphere we call home. It is such a common problem that every program that run on computers in space must be designed so that should an ionising event occur (and there are a number of different types causing differing effects) the program will be able to detect as much and either reset or shut down the computer to prevent further damage. Therefore, if an event occurs in this way and does cause a problem then i would suggest that this is a failure of the programming to anticipate a known and likely event and to precipitate the correct instructions. So yes this is a user/programmer error.

On your last point "So what do we need Gods for then?", well the fact is that we as rational sentient beings do NOT need gods. But some people still feel more comfortable believing in a higher power/sky fairy/etc. That is life... It has no bearing on the differences between computer errors and user errors.

Finally to refute your argument i offer this - Can a knife be in error? if it cuts someone is that the knifes fault or the users? If the blade is dull perhaps that counts as an error? Or is that an error of the user for not sharpening the knife? Obviously a knife can be broken, but will a knife every break on its own? So that would be the users fault for using the knife incorrectly, no?

By the same logic is there any dumb object that can be said to make an error? I would say no, only the user of a dumb object can cause the error. And computers are no more then dumb objects, we attribute more to them then most things because they are so much more complex but all of that complexity is down to either programming or user control. So any errors i would suggest automatically fall into those categories...

Just a thought...

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FAIL

Re: Act of God

I think you are confused between error and failure. Here's the thing, a computer is just like a hammer or gun. Imagine, "yes doctor, my thumb is smashed because my hammer made an error" or "I'm sorry officer, the gun had an error and it just shot him dead". You see, it's possible the handle of the hammer broke at an inopportune time and smashed the thumb and it's equally possible that the safety mechanism on the gun broke during unsafe handling. But you see those are failures not errors. Likewise a large rock fallen from the heavens can cause a computer failure upon impact but not an error. Consider the origin of the phrase, "to err is human".

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Stop

QED or NOT

As a comment to the statement "There are NO SUCH THING as computer errors, just human mistakes.", I think my examples to the contrary (not analogies) are perfectly OK.

But lets go on a bit and include lightning strikes, office/domestic fires, flooding, earthquakes, hanging dimples, smudges on the glass of a scanner, high humidity, process variation at the memory manufacturers facility etc.

I am very well aware that many errors contributes to computers are avoidable if the correct human actions are taken at the correct time. But that does still not make ALL computer errors into human errors.

P.S.

The fact that I have never seen ionizing radiation affect a computer is closely related to the fact that it is rather difficult to observe and determine as the exact cause of error - NOT to the fact that it doesn't happen at sea-level.

Radon radiation is highly ionizing and is present in all concrete buildings.

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Headmaster

Not an analogy, but anyway

We are approaching a discussion of semantics here.

A knife can be said to have a fault or a weakness.

If it breaks due to this weakness I may blame the manufacturer, but ultimately it may have failed due to a number of causes outside his or my control (any examples I may offer here are likely to get me blamed for more exaggerated examples, so I will refrain from making any)

Books are also said to contain errors, which are most often attributed to pixies (or typesetting if you want to be more literal), but can also encompass such things as pages missing or being doubled up or in the wrong order, which to my personal experience with auto-collating units does not have to be due to handling errors.

All physical communications have some level of error (also known as noise)

Calculations involving rational numbers (except a very small percentage that can be calculated exactly using symbols) also contain errors - no matter whether they are performed on a computer or by a human.

So - if your argument is that the word "error" can only be attributed to humans, you are arguing against common practice.

And no matter what you name this kind of happenings, it is still possible (but admittedly maybe not the most likely) that sometimes such a fault could NOT have been prevented by a human involved.

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Happy

ermmm

ECC Reg Memory for the win :)

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FAIL

Computer error?

Or a cock up in design or programming?

I think likely to be the the latter two...

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Phew!

"The NHS Blood and Transfusion service stressed that only 21 people had died"

Phew! That was a close call, 'only' 21.

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FAIL

hmmm

user error != computer error

Computer is working fine - i just wonder where the inputers are from...

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Unhappy

...an Indian data processing office probably

If doctors' notes are sent abroad for processing then maybe the transplant forms are too. Maybe the inputters found it quicker to select "any body part" rather than to select the exact ones the donors wished to give.

I am a willing donor and selected everything except my retinas. I spent nearly an hour thinking this over so I'd be rather annoyed to learn that the control I have over which parts are donated have been ignored.

I agree with the others - no way is it a computer error. Computers can not make mistakes, only programmers and users can. It's like saying my diesel car made a mistake and filled itself up with petrol.

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Anonymous Coward

AC@10:24

"If doctors' notes are sent abroad for processing t"

Not sure about doctors notes but a subsidiary of Hayes pitched a system which scanned images, uplinked then to an Indian data centre for reading and keying and downlinked the result to UK databases. This was done by Scottish NHS and was viewed as quite a success. The individual prescription pages were split up in sections and passed to different operators and double entered for accuracy. Oddly one part of the NHS IT project was paperless transmission of prescriptions from surgery to pharmacy, which should have made this obsolete once the backlog was done.

I'm sure they were pitching to hospitals to clear their patient records.

Brilliant in theory. We called it ICR.

Not so sure in practice.

AC as some people might not like this to be known.

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Anonymous Coward

Cause = DVLA

Hearing about how crap the DVLA is (cf WatchDog on BBC1), I wouldn't be surprised if the DVLA were the cause of the data problems.

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Ah, but

if it's a computer error then "no-one was really to blame". If it were down to a person then there would be fault to be found, blame to be assigned. This way hands can conveniently be washed (or, more probably in the case of the NHS, not washed).

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Nearly right...

"At the source of every error which is blamed on the computer you will find at least two human errors, including the error of blaming it on the computer".

- Anon

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FAIL

Accident or Design?

Would not be the first time a data entry field was left off the input screen.

Don't blame the inputters so quickly. They are are expected to perfom day after day like robots, data blindness can and does occur as a result of the sheer volume of work processed. In fact it's not uncommon to see even seasoned veterans faint and headbut the keyboard on a regular basis. So even if they do confront the keyboard thumper chances are that they will not remember the specific file or anything else that happened that day.

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FAIL

Scoop out all the good bits...

...and give the rest to medical science.

I have to agree with my fellow commentards though, sounds like PEBKAC to me!!

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Coat

Computers CAN make mistakes

...if they have a manufacturing fault, or overheat, or receive sharp knocks or vibration, or experience power fluctuations, or are short circuited by moisture/insects/hair/other foreign matter, or are struck by cosmic rays, or any of hundreds of unpredictable phenomenon.

Pedant I may be but please don't assume absolutes so readily.

Mine is the one correctly labelled 'overcoat'.

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Headmaster

all still human problems. it's just a matter of what human get yelled at.

...if they have a manufacturing fault,

(human) design error

or overheat,

(human) design error

or receive sharp knocks or vibration,

(human)design/enviromental issue

or experience power fluctuations,

(human)design/enviromental issue

or are short circuited by moisture/insects/hair/other foreign matter,

(human)design/enviromental issue

or are struck by cosmic rays,

(human)design/enviromental issue (yes kiddies, even this can be protected against, It's just useually not worth the money to do it)

or any of hundreds of unpredictable phenomenon.

We design a machine to operate under specified tolerances. If it fails while within the tolerances that's a human design problem (the machine doesn't operate in spec). If it fails while operating outside the operating paramiters, that is an enviromental design issue (you monkeys need to stop peeing on the kit), which is again a 'human' (i use that in the loosest sence of the word) problem.

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Opt out

I decided not to donate after a long chat with various members of family at each end of the country working in various hospitals - none of them donate either. Tales of how donation cards can affect treatment (and comments made by consultants) was enough to put me off. The idea that a "Mr" may decide to not give me that extra chance simply because he thinks my organs are more valuable to someone he knows that to me was enough to put me off. And if you dont think this does not happen, think again - doctors are people and if they have a patient desperate for a transplant it is very difficult for them not to think of someone (even if only subconciously) that is unlikely to survive a serious car accident as "spare parts".

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Boffin

Doesn't compute

Sorry, Jacqui, but that does not make sense. The doctor who treats you does not get to decide who gets your organs or even remove them. When you are pronounced dead by 2 certified doctors who check your vital functions and brain activity twice after a defined waiting time, the hospital calls Eurotransplant in Amsterdam who work out from their lists who gets what and sends in a team to harvest the organs and has them transferred asap.

The actual recipients are those who are the best fit, need the organs most badly and are close enough for the organs to reach them on time.

There are very rigid procedures and the doctor who's treating you isn't really involved except that he is probably one of the two who pronounces you dead.

Organ donation save lives - at least until we can grow organs in a petri dish - and you certainly won't be needing them any more.

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FAIL

Opt-Out

Another incident to make me glad I got my opt-out form in.

But also a reminder to check that the opt-out has actually been registered.

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Megaphone

Simple solution

Ban opting-out of organ donation.

Living people have rights, pieces of meat don't. To burn or bury an organ that could have saved a life is, quite simply, an act of supreme selfishness that does not fall far short of murder.

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FAIL

analogy

So following your (somewhat flawed) logic, when you die, state should take of control of all your remaining financial assets and distribute them to other needy people and disregard your will?

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Re: Ottman

I think you misunderstand. Your estate will *always* benefit someone (presuming you have one). The value of it is not destroyed upon your death. Your cadaver however is generally left to rot or burnt providing no benefit to anyone.

The equivalent with your estate is to destroy your house, salt the earth it was built upon, burn all your goods and cash. Note that burning cash is something not permitted by law.

Funny how the law protects cash but not body parts. What he's actually saying is the law should be the same for both. You *have* to give your cash to someone, even if it ends up being el Gov, why shouldn't your organs be subject to the same requirement? No, that's not rhetorical.

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Megaphone

Organ database? Why bother?

We shouldn't have to bother with such a database anyway. Let's just make it the law that everyone donates everything unless they wear a 'medic aware' bracelet to indicate otherwise. Even in the time taken to check records someone could do waiting for an organ.

Most people who are not registered donors simply haven't got around to it. People who actively opt-out should have to make an effort (and put to the end of any recipient list, of course - selfish bastards), and wearing a bracelet is something I'm happy to see them have to do. Why should we all subsidise their selfish ways?

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Big Brother

Re : Organ database? Why bother?

And to make it easy for the medics to match up organ donors to recipients lets have every one in the country, and tourists and 'travellers', give DNA samples so that every one could be pre-matched, 'just in case'.

Of course we'd have to tattoo ID's or numbers on every one to ensure that "The Authorities" know who each body is. Tagging or RFID chips would also help. After all if an important person, someone whom the country just couldn't do with out (i.e. a politician or government minister, or, God forbid, the Prime Minister) suddenly _needed_ an organ, well then the doctors would know who to look for, and where to look too. My, my, wouldn't that save time.

Oh yes I do like your reasoning.

And we're all totally convinced that our glorious leaders would _*never*_ abuse such a system.

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Anonymous Coward

@Jacqui

Don't know what your family have told you, but the chances of a "Mr" passing judgement on someone in A&E *AND* having a patient who needs a transplant *AND* the someone in A&E being a close enough match for his patient *AND* there not being someone ahead of his patient on the transplant waiting list are pretty damn minimal.

And I hope that because you and your family have made the decision not to do this, you would also never accept organ transplants, even to save the life of your child or husband. Yeah?

FWIW, solving the problem of getting enough transplant donors and blood donors is actually very simple. You register your preferences for/against, and if you don't want to make donations then you don't get donations. Simple as that. And of course you don't get to change your mind once you're terminally ill. "Dr Faustus" had that right - once you've made your choice, it's too late to back out when you find the Devil's coming for you.

Also FWIW, if there was a choice of me "recovering" from a car accident paralysed and with massive brain damage, compared with pulling the plug so my various bits and pieces allow a dozen other people to continue (or start) healthy and fulfilling lives, then it's no choice at all - break me for parts ASAP. That's what my Living Will says, and my wife's.

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Gold badge
FAIL

DVLA IT f£$kup or NHS IT f£$kup ?

Decisions, decisions.

I'll plump for one but admit it could be a double fail.

Which end do other people think it is?

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Anonymous Coward

Oh noes!

"We've come for your liver."

"But I'm still using it."

"What's this then?"

"An organ donor card."

"Need I say more?"

"Listen! I can't give it to you now. It says, 'in the event of death'."

"No one who has ever had their liver taken out by us has survived."

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So, a mismatch between two databases has caused problems

Now, if we only had a single national ID system...

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Gold badge

"Computer Error"

Because computers don't stick up for themselves and, most importantly, you can't fire a computer.

That's why.

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