title: Wrong site frenulectomy in a child: a serious safety event.
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.
authors.affiliation: 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.
authors.forename: Sally
authors.initials: S
authors.lastname: Rampersad
authors.forename: Michael G
authors.initials: MG
authors.lastname: Rossi
authors.forename: Christie
authors.initials: C
authors.lastname: Yarnell
authors.forename: Tetsu
authors.initials: T
authors.lastname: Uejima
mesh_terms: D005260:Female; D006801:Humans; D007223:Infant; D008035:Lingual Frenum / Q000601:surgery*; D019300:Medical Errors; D061214:Patient Safety