Because it&#x27;s really disingenuous to say that the medical device industry hasn&#x27;t learned anything from Therac 25. The concept of two-fault failures is an industry standard that was learned from Therac.<p>The fact is that in the Medical software industry the best practice is to manage the entire software configuration of the medical device. Failing to do so, and especially failing to adhere to the guidelines of the manufacturer, is negligent at best. We all know that the behavior that led to the hazard is the wrong thing to do and that somebody screwed up.<p>The only other real insight that can be gained from this incident is that it&#x27;s very important to have configuration management procedures that are easy to follow, and it&#x27;s important to verify that they were correctly followed. I can&#x27;t tell whether they were in this case, but I suspect given the use of Off-the-shelf software that there was some manual sequence of steps required to adhere to the approved configuration. Given that, I would have expected an error of this magnitude, because it&#x27;s well known that humans make mistakes whenever they are made to follow a sequence of steps. The configuration should have been verified at installation time, at least.<p>If you&#x27;re interested in the kinds of things the industry has to consider in the US, take a look at the FDA guidance for the 510k submittal process.