ABSTRACT
Introduction The overexposure of LN to radiation did not come about because the staff at the Beatson Oncology Centre lacked resilience to a new threat to its standard, vigilant safe operations. The overexposure happened because the most elementary precautions of user testing of a computer system upgrade, before system acceptance and actual use, were never, I believe, carried out. In fact, it is difficult to find in the investigation report any reference to software testing, acceptance criteria, test cases, or user training on a live system.
