Human Error Identification
An Analysis of Myringotomy and Ventilation Tube Insertion
Mary-Louise Montague, MRCS;
Michael S. W. Lee, FRCS;
S. S. M. Hussain, FRCS
Arch Otolaryngol Head Neck Surg. 2004;130:1153-1157.
Objectives To use a human reliability assessment tool to identify commonly occurring errors during myringotomy and ventilation tube (VT) insertion and to quantify the likelihood of error occurrence.
Methods Error-free task analysis for myringotomy and VT insertion was defined at the outset. Fifty-five consecutive myringotomy and VT insertion procedures were videotaped. The operator was either the senior author (S.S.M.H.) or a trainee in the specialist registrar or senior house officer grade. Three assessors (M.-L.M., M.S.W.L, and S.S.M.H.) blinded to operator identity independently evaluated each procedure. Interobserver agreement was calculated ( values).
Results Twelve potential error types were identified. A total of 87 errors were observed in 55 procedures. In 53% of procedures (n = 29) multiple errors were identified. Seven percent of procedures (n = 4) were error free. The 4 most frequent errors identified were (1) failure to perform a unidirectional myringotomy incision (n = 37; 43%); (2) multiple attempts to place VT (n = 14; 16%); (3) multiple attempts to complete the myringotomy (n = 11; 13%); and (4) magnification setting too high (n = 11; 13%). The human error probability was 0.13. Interobserver agreement as expressed by statistics was high.
Conclusions Human error identification in this most common of otologic procedures is crucial to future error avoidance. Eliminating the 2 most common errors in this model will halve the human error probability. Extending the role of error analysis to error-based teaching as an educational tool has potential.
From the Department of Otolaryngology, Ninewells Hospital and Medical School, Dundee, Scotland. The authors have no relevant financial interest in this article.
RELATED ARTICLE
Striving for Imperfection: Facing Up to Human Error in Medicine
Molly Zirkle and David W. Roberson
Arch Otolaryngol Head Neck Surg. 2004;130(10):1149-1151.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
The Difficulty of Identifying and Enumerating Human Errors
Berry
Arch Otolaryngol Head Neck Surg 2005;131:539-539.
FULL TEXT
The Difficulty of Identifying and Enumerating Human Errors--Reply
Hussain
Arch Otolaryngol Head Neck Surg 2005;131:539-539.
FULL TEXT
Striving for Imperfection: Facing Up to Human Error in Medicine
Zirkle and Roberson
Arch Otolaryngol Head Neck Surg 2004;130:1149-1151.
FULL TEXT
|
