Skip Navigation LinksHome > July 2014 - Volume 119 - Issue 1 > Wrong Site Frenulectomy in a Child: A Serious Safety Event
Anesthesia & Analgesia:
doi: 10.1213/ANE.0000000000000267
Pediatric Anesthesiology: Case Report

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§

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Abstract

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.

© 2014 International Anesthesia Research Society

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