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Wrong Site Surgery–Wrong Tooth Extraction.

Farnborough, UK: Healthcare Safety Investigation Branch; April 22, 2021.

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June 9, 2021

Farnborough, UK: Healthcare Safety Investigation Branch; April 22, 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.