The article entitled “Human Error Identification: An Analysis of Myringtomy and Ventilation Tube Insertion,” which appeared in the October 2004 issue of the ARCHIVES, dramatically underscores the problems of human error identification, since the authors themselves had a human error in their evaluation.1 They describe a sequence of 10 steps that need to be completed appropriately for the entire procedure to be deemed error free. They should have had a sequence of 11 steps. One very important step was omitted, one that would ensure that epithelium does not grow into the middle ear. When a radial myringotomy incision is carried out under the conditions that the authors suggested, this step is left out.
Berry YJ. The Difficulty of Identifying and Enumerating Human Errors. Arch Otolaryngol Head Neck Surg. 2005;131(6):539. doi:10.1001/archotol.131.6.539-a