Therac-25 放射線事故
Contents
1. 1 20 0 000000 LD 25 00000000000 0000 00 Bowsher 19900 00000000000000 00000 0000 000 000 0 0 0 0 000 Anderson J Goodman W Ethics Information Technology Case based Approach to Health Care System in Transition Springer 2002 Bowsher C A Medical Devices The Public Health at Risk US Government Accounting Office Report GAO T PEMD 90 2 046987 12. RE T 488 ienero gals TAUGE TETAS EE ARDE M EEDA 5 ibia AEE 0 EPET TrA TETTO AE E 12 LEEA EN 1 ERARI yy guirejar UTEM RATATE aBa 4 4A FRE T 4 A boirar T Biz i Ei o d A 000 000 20 00000000 25
3. 00 000001 0 25 3 25 000 5400801 4 0000000 00000 0 00060
4. 1 00 25 000000000000 0 25 0 000 0000 0000 00000 0 00000 000 0000 00000000000 0 hansi 00000 00000 0 0 00 0 0 000 25 0 0 00000000
5. 0 L Therac 250 0 000000000 Therac 200 00000000000 00000 000 20 000000000 0 00000 60 00000 0 00000 0 8 1 8 1 25 1 20 00000 00 nuisance 00000 00000 00000 0 00 00 0000000000 Therac 20 0000000000000000 00000 2 000 0 0 8
6. 39922 1990 Leveson N G and Turner C S An Investigation of the Therac 25 Accidents in Johnson D G and Nissenbaum H eds Computers Ethics amp Social Values Prentice Hall pp 474 514 1995 2006 by Shigeki Higashimoto Yohko Orito and Murata This case may be quoted or published without permission as long as it is not changed in any way and it carries the copyright notice 000 oooi
7. 60 0 00000 0 00000 00000 251 5 000 0000 00000 AECL 0 0 0 25 0 0 0 0000 19850 100000000000 1 1 0000000000000000000 00 Anderson Goodman 2002 O O 00 6 00000000 Leveson and Turner 199 00 0 00000 00000 00 6 00000 000
8. Therac 250 0000 Therac 25 0 0000 0 0000 00000 000000000 0000000 1983600000000 1000000 1985000 198700000 6000000000000 00000000 0 00000 25 emey 1 00000 61000 0 0 0 2 00000 000 Therac 20 0 Therac 2000 0 000000000 Therac 6 000 Therac 25 00000000 20 0 0 00 0 0 0 25 0 0 25 0 1983 000 0000 1985 0000000000000 20 000000000 0000 19850 600000000000 0000000000000 700000 12 00000000 19860 30 20000000 19870 10 0 00000000000000 00000000000000 1000
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