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Letters to the Editor
June 2005

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

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.

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