-
- Slip: right intention with
wrong action
- Mistake: wrong intention and
right action
- The technician made a slip
- Design so that the machine can
not emit dangerous levels of radiation without the plate being present. (constraint,
forcing function , lockout are acceptable too, interlock + training are
wrong).
- a. Perception
of patient: visual + auditory
b. Interpretation of event: knowledge that the
machine fired high level of radiation
c. Evaluation: treatment not received, patient
injured.