Price of poor instructions: the Cutter case

[Gene Kim-Eng]

A good lesson for those who don't do
any testing, as well.  :)

Gene Kim-Eng


----- Original Message ----- 
From: "Stuart Burnfield" <sburnf at au1.ibm.com>

> People sometimes ask on the list for examples of inadequate technical
> instructions that led to loss or harm.
>
>   The Cutter Company,
>   the smallest of the five licensees, followed the government’s
>   instructions to the letter, but failed to kill all the virus in the
>   vaccine. Seventy thousand people suffered mild forms of polio. Two
>   hundred were paralyzed. Ten died."