Related Experiment Video
Updated: Aug 11, 2026
Guidelines for Elective Pediatric Fiberoptic Intubation
Published on: January 18, 2011
Wrong site frenulectomy in a child: a serious safety event
Sally Rampersad1, Michael G Rossi, Christie Yarnell
1From 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.
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.
