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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.

After the incision is made and the middle ear is aspirated, a ventilation tube is inserted. Of course, the ventilation tube will push the 2 sides of the incision away from the tube. However, these 2 raw edges can invert, but we must ensure that they evert. The way to do this, of course, is (1) to use a very small, No. 24 suction tube; (2) to elevate the flange of the tube, which is now against the tympanic membrane; and (3) to suction out the edges of the incision. Following these steps will ensure that nothing is tucked into the middle ear, where it could form a cholesteatoma.

This procedure is added as a surgical task to avoid the potential complication of a cholesteatoma. Of course, the cholesteatoma would not be noticed for a long while. This omission shows how difficult it is to identify all of the steps with any procedure, even a simple myringotomy and ventilation tube insertion. Identifying all the steps is a good beginning, certainly, but to do so is very difficult, not only because there are steps that have not been thought of but also because some surgical tasks are unpredictable. For instance, we do not always know a bleeding site, nor have we decided on the best way to control bleeding, eg, suture ligature, cautery, or packing.

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Article Information

Correspondence: Dr Berry, Departments of Otolaryngology, Tufts University School of Medicine and Harvard Medical School, 1842 Beacon St, Brookline, MA 02445-1930 (yalebee@verizon.net).

References
1.
Montague  MLLee  MSWHussain  SSM Human error identification: an analysis of myringotomy and ventilation tube insertion.  Arch Otolaryngol Head Neck Surg 2004;1301153- 1157PubMedGoogle ScholarCrossref
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