As implied by the name, “Never Events” should never occur. Health care registries can capture such sentinel events, facilitating root cause analysis to help determine how to prevent their recurrence. Dr. Sally Rampersad, Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, Washington, and colleagues describe an episode where a 13-month-old child underwent a lower frenulectomy rather than the intended upper frenulectomy. After describing the case, the authors discuss the root cause analysis and safety analytics for the event in their article titled “Wrong Site Frenulectomy in a Child: A Serious Safety Event,” published in this month’s issue of Anesthesia & Analgesia.
The patient was scheduled to have an upper lip frenulectomy. The surgeon was given an extra room so he could finish earlier because his schedule on that day was especially busy. Although the anesthesiologist in the primary OR had seen the patient and was aware that the procedure was an upper lip frenulectomy, this information was not communicated to the anesthesiologist in the second OR to which the procedure had been transferred. The surgeon did not see the patient on the day of surgery, so the parents were unable to remind him that the procedure involved the upper lip. The surgery resident who obtained consent for a standard tongue tie release but thought that the tongue tie was minor and did not question the surgeon. The OR staff was also unaware of the correct procedure. A time-out was performed after induction. Instead of an upper lip frenulectomy, a lower lip frenulectomy was performed. The parents noted the mistake in the PACU, whereupon the child returned to the OR for the proper procedure.
Because the patient was exposed to an additional unnecessary general anesthetic and also had a minor procedure performed that was not indicated, this would be classified as a Serious Safety Event (SSE) type 4, with severe temporary harm. In fact, this could arguably be classified as a SSE 3, moderate permanent harm to the child, since the original surgery cannot be reversed. In addition, according to National Patient Safety goals, wrong site surgery is a “never event.”
As part of a root cause analysis, the first step is to gather the facts through examination of records and staff interviews. A timeline is developed and team representatives are assembled corresponding to the individuals involved, though not the actual individuals. These team members will analyze events and look for means to improve care, including ways to prevent recurrence in the future. Policies are checked: in this case, there was no policy stating that the OR schedule had to be matched to the consent form. Proximate causes, which are the root causes that allowed the error to occur and if corrected should prevent a recurrence, are that the resident obtained the wrong consent, and there was no expectation that the surgical site would be marked for this type of procedure.
Contributing factors are important factors that should be addressed, but alone they would not have prevented the occurrence of the event. Some of the contributing factors in this case include the fact that the electronic record did not provide adequate free text space to describe a nonstandard procedure, the resident did not question the attending surgeon despite having concerns that the tongue tie seemed “minor, and the attending surgeon did not see the patient/the patient’s family on the day of surgery.
The surgeon and anesthesiologist both immediately disclosed the event to the family because they needed to obtain consent to give a second general anesthetic to complete the correct procedure. Risk Management was also informed of the error.
The article does not specifically address the role of switching rooms to expedite the surgical schedule, other than noting that the originally assigned attending anesthesiologist did not communicate to the newly assigned attending anesthesiologist that the surgery was moved out of my room. Sometimes there is no communication with the newly assigned anesthesiologist, particularly when everyone is pushing hard to turn over cases as fast as possible because the surgeon has overbooked the room.
However, part of the story is that patient injury may occur when the push for OR efficiency compromises existing checks and balances.