Wrong site frenulectomy in a child: a serious safety event.

作者信息

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

机构信息

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.

出版信息

Anesth Analg. 2014 Jul;119(1):141-144. doi: 10.1213/ANE.0000000000000267.

DOI:10.1213/ANE.0000000000000267

PMID:24945126

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.

摘要