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Harvard Brain Bank Failure: Temperature Monitoring

Jan 24, 2013
BrainBankFreezer

Background

A little over a month ago, the Temperature@lert team uncovered yet another frightening "monitoring" tale from the Boston Globe from Summer 2012. The article, centered around Harvard's Brain Tissue Resource Center at McLean Hospital, referred to herein as the "Harvard Brain Bank", outlines a recent failure that affected several years of medical data.

 

Here's a few statistics that crunch the data:

Total Number of Lost Samples 147
Time to Collect Samples 14+ Years
Percentage of Lost 'Autism' Samples  37%

In all, the 'Autism' samples represented nearly a quarter of all available 'brain samples' that are used for Autism research. The loss of years' worth of data is an outright tragedy and will merely be remembered as 'lost work'. But how did this happen? How could the Harvard Brain Bank be so careless with precious brain samples? Aren't there best practices that are designed to prevent this type of disaster?

The answer is, there are both 'best practices' and specialized devices that support them. The shocking truth in all of this, is that the Brain Bank's 'best practices' were not the cause of this failure. In fact, the losses were caused by failure of their own specialized devices. 

(Read the original Boston Globe article here)

 

What Happened:

The Harvard Brain Bank houses about 24 freezers for their brain samples. Each of the 24 freezers are equipped with a digital readout for temperature. The freezers are supplemented by a backup system that detects freezer failures. In concept, this two-step 'confirmation' system should be enough to detect failures before they become critical problems. 

Unfortunately, their two-step system failed on both fronts. Staff at the Brian Bank discovered  that Freezer 'U' had lost power several days earlier. This particular freezer showed a normal digital readout (-79 degrees Fahrenheit) despite having lost power, and the backup system failed to recognize the problem. Once making this discovery, the staff realized that 147 brain samples had defrosted, and were no longer suitable for use. A leading Autism researcher commented that "so many autism brain samples should not have been stored in one freezer" and questions still exist as to why the samples were not distributed amongst the other 23 freezers. Regardless, their solution had a systematic breakdown that stemmed from a simple power outage.

The Lesson:

We can all shake fingers, rattle cages and roll heads to prevent this disaster from happening again, but the more important thing is to identify the solution of the future and learn from these mistakes. Reality is, priceless data and research is often protected by simple technology, and these devices, for better or worse, are not always perfect. For this particular example, the failure was embedded in the power supply. The digital readouts and the backup systems were rendered useless without access to power, which seems like a common-sense consideration. Power can go out at anytime, but should your systems also fail simply because of lost power?

 

The Solution

Of course not! From the storage of valuable research material, all the way down to a simple server room, temperature devices should have a secondary connection option. A secondary connection would allow the device to transmit readings despite losing power from a common power outage.  With this feature, caretakers can receive notification of rising/falling temperatures during an outage. This is the ideal solution, especially when contrasted with the 'sudden discovery' of damaging temperatures in the days afterward at the Harvard Brain Bank. Any temperature monitoring solution that solely relies on AC power, is hardly a solution at all!

Our Solution

For this specific reason, we've fitted our Temperature@lert Cellular Edition with backup power functionality. Readings can be transmitted during outages with the pre-installed backup supply. Even with telephone lines down, the Cellular Edition utilizes the mobile phone networks to deliver timely alerts. We hope that other critical storage facilities are aware of this case-in-failure, and we're glad to offer a "dual-power" temperature monitoring system.  For more information on the Temperature@lert Cellular Edition, please visit our products page.

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