Danger to Life and LimbBy Ericka Chickowski | Posted 2009-05-15 Print
Big IT projects sometimes go wrong in spectacular ways, with some common themes running through the disaster stories like fault lines.
The ultimate cost of some bungled projects is human life.
Kaiser Kidney Transplant Center Debacle
Only two years after opening, the Kaiser Permanente Kidney Transplant Center in San Francisco was forced to shut down in the wake claims that it risked patient’s lives through delays brought on by bureaucratic bungling.
According to whistle-blowers, patients, and regulators, Kaiser’s lack of planning in data-management governance, procedures and policies for the setup of its Kidney Transplant Center delayed the entrance of countless patients into the operating room to receive vital surgeries. Kaiser is said to have never set up procedures to transfer patient data from prior transplant facilities. or to have compiled a database of records for patients transferred into the center’s program. Administrative staff did not have a clear set of written directions to do their jobs and had little experience in the transplant specialty.
In one example, patient Bernard Burks was told by his insurer, Kaiser, that he had to transfer from a kidney transplant center in Sacramento to Kaiser’s new facility in San Francisco in order to continue to receive coverage. In the process Kaiser lost his records and he was somehow bumped to the back of the line for a kidney, even though he had already accumulated three years’ credit at his former facility. When his daughter stepped forward to donate, that information was mismanaged, too.
Burks’ experience wasn’t isolated. In February 2006 an internal whistle-blower, David Merlin, blew the roof off the story when he went to the Los Angeles Times and other media outlets with concerns. By May 2006 regulators at the state Department of Managed Health Care (DMHC), Medicare, and Medicaid released scathing reports on the matter, and Kaiser decided to shut the whole transplant operation down. Kaiser was later fined $2 million by DMHC, and it voluntarily paid another $3 million to a transplant education group to atone for its missteps.
Lessons Learned: Regardless of the technology used, governance and compliance must be in place in order to properly manage information in the enterprise.
Trains, planes, and automobiles rely on software to improve engine performance, control electrical systems and keep navigation systems running. But when developers and QA testers miss something in the code and bugs crop up, resultant glitches can risk lives and damage reputations.
Last February, just that kind of problem cropped up at Ford. The car manufacturer was forced to recall nearly half a million 2005-2008 model Mustangs after discovering that a software problem in these cars caused airbags to be deployed forcefully enough to cause neck injury to smaller passengers not wearing seatbelts. Mustang owners had to return their vehicles to the dealer in order to receive a software update to the Restraint Control Module within the car computer.
While no injuries related to the error ever occurred, Ford paid to notify customers and conduct the recall. Developers and testers of all stripes should sit up and take notice of this classic software failure scenario, born out of inadequate testing before the product went to market. Ford only found the discrepancy during safety crash testing mandated by the National Highway Traffic Safety Administration.
Lessons Learned: Testing may be expensive, but it’s a lot cheaper to get the code done right the first time.
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