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Wrong Site Frenulectomy in a Child: A Serious Safety Event

Rampersad, Sally MB*; Rossi, Michael G. DO, FAAP; Yarnell, Christie MD; Uejima, Tetsu MD, MMM, CPHRM§

doi: 10.1213/ANE.0000000000000267
Pediatric Anesthesiology: Case Report

Wrong site surgery is a serious safety event that can result in temporary or even permanent harm. Various safety checklists and procedures have been added to our standard work in the operating room, but errors still get through our safety nets and patients are harmed. In this case report, we describe a wrong site frenulectomy in a child and discuss the root cause analysis of this error and also SMART (specific, measurable, achievable, realistic, timed) preventative actions that could be put into place to prevent a recurrence.

From the *Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, Washington; Division of Anesthesiology, St Jude Children’s Research Hospital, Memphis, Tennessee; Division of Pediatric Anesthesia and Pain Medicine, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, Arkansas; and §Department of Anesthesiology and Critical Care Medicine, Nemours/AI DuPont Hospital for Children, Wilmington, Delaware.

Accepted for publication March 25, 2014.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Sally Rampersad, MB, Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital and University of Washington School of Medicine, 4800 Sand Point Way NE, MB.11.500.3, Seattle, WA 98105. Address e-mail to: +sally.rampersad@seattlechildrens.org.

© 2014 International Anesthesia Research Society