Checklist problems 2 – Case 317
A 4 year-old child was listed for umbilical hernia repair. On the day of surgery, the child was upset and difficult to examine. In an attempt to placate her, the trainee drew a midline ‘smiley face’ as a site mark in the epigastrium. Consent was taken for umbilical hernia repair. The child came to theatre with their parent and was checked in, though the site mark was not inspected. Once in theatre, the ‘time out’ was performed before the surgeon scrubbed and the patient prepared and draped. The trainee scrubbed with a junior colleague and started the procedure, making an incision in the epigastrium at the site of the site mark. The consultant entered theatre just after the incision was made and noted the error. The consultant then scrubbed in and undertook the correct procedure. The family were informed and received feedback from the root cause analysis investigation.
