
403Human Factors
visible in real time. Only later do burns or other symptoms reveal that mis-
takes have been made. In the meantime, the patients must have faith that
everyone involved has done their job correctly.
Many different types of errors will cause problems. Software bugs can
create a disconnect between the instrument readings and the actual power
output. Calibration errors, inappropriate hardware congurations, and poor
documentation of procedures have killed or injured patients. Unlike surgical
procedures, it is difcult to catch the errors in real time. Fatal mistakes have
been repeated over a period of years before they are detected. ...