Wrong-Site Frenulum Procedural Interventions

Harm range: No detectable harm to moderate temporary harm.

Wrong-site procedural interventions involving the frenulum may be on the rise. From 1997 to 2012, frenulum procedural interventions increased 866%. These procedures require difficult tissue marking in the oral cavity and high precision. In addition, safety events are more likely to occur when a patient undergoes multiple procedures in which one or several sites are difficult to mark. These factors, along with the significant rise in frenulum procedures, cause a high risk of wrong-site procedures. Common causes include:

• Relying on memory of the correct surgical site instead of a verbal and visual reminder. 
• Lacking vital components or team members in pre-operative time-outs, leading to insufficient communication and verification of the correct procedure or site.  
• Using generic procedural names during the scheduling process and on consent forms, causing confusion in anatomical site and procedure. 
• Completing more than one procedure during the surgery without additional verification and team consensus of procedural details. 
• Unclear communication during the family procedure review in the pre-operative period.

Performing interventions on the wrong site has led to repeat visits to the operating room and prolonged anesthesia requirements. These safety events may cause increased operating room time, resources, and costs. 

Immediate recommendations

1. Encourage use of detailed procedural names in surgery scheduling practices. 
2. Ensure consent verbiage includes precise anatomic location of procedure and require use of electronic consents to confirm essential fields are completed. 
3. Standardize a clear and thorough verification process with the family pre-operatively on the day of surgery. 
4. Utilize diagrams or visual aids for difficult-to-mark sites.  
5. Implement a brief but robust and standardized time-out once the patient is correctly positioned for the operation. Include key stakeholders, review the consent and procedures, and communicate new or essential information, including any “add on” procedures. Initiate separate intraoperative timeouts before each additional procedure. 

Download the safety watch and review the Child Health PSO Wrong-Site Surgeries/Procedures Safety Alert.

References

• American Academy of Pediatric Dentistry, Policy on Management of the Frenulum in Pediatric Patients, 2022
• Up to Date, Ankyloglossia (Tongue-Tie) in Infants and Children, 2023

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