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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 . . . [Full Text of this Article]

AUTHOR INFORMATION
Yale J. Berry, MD

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