Wrong site frenulectomy in a child: A serious safety event

Sally Rampersad; Michael G. Rossi; Christie Yarnell; Tetsu Uejima

doi:10.1213/ANE.0000000000000267

Wrong site frenulectomy in a child: A serious safety event

Sally Rampersad
, Michael G. Rossi
, Christie Yarnell
, Tetsu Uejima

University of Washington
St. Jude Children Research Hospital
University of Arkansas for Medical Sciences
Alfred I. duPont Hospital for Children

Research output: Contribution to journal › Article › peer-review

5 Scopus citations

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.

Original language	English
Pages (from-to)	141-144
Number of pages	4
Journal	Anesthesia and Analgesia
Volume	119
Issue number	1
DOIs	https://doi.org/10.1213/ANE.0000000000000267
State	Published - Jul 2014
Externally published	Yes

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10.1213/ANE.0000000000000267

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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.",

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AB - 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.

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Wrong site frenulectomy in a child: A serious safety event

Abstract

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