An adverse event trigger tool in dentistry

Kalenderian, Elsbeth; Walji, Muhammad F.; Tavares, Anamaria; Ramoni, Rachel

doi:10.14219/jada.archive.2013.0191

Cited by 52 publications

(41 citation statements)

References 11 publications

(10 reference statements)

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“…It would be improbably optimistic to assume that these events represent the sum total of device-associated AEs in American dental practices. Indeed, as reported in a 2013 Journal of the American Dental Association publication authored by RR, EK, and MW, we found that 34% (95% confidence interval 22% – 48%) of randomly-selected patient charts from an academic dental center with both teaching and faculty practices contained at least one AE (22), a number of which were device-related, e.g., fractured removable partial denture, fractured implant. None of these were voluntarily reported to MAUDE by the clinic.…”

Section: Discussionsupporting

confidence: 72%

The dangers of dental devices as reported in the Food and Drug Administration Manufacturer and User Facility Device Experience Database

Hebballi

Ramoni

Kalenderian

et al. 2015

The Journal of the American Dental Association

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Objectives To determine the frequency and type of adverse events (AEs) associated with dental devices reported to Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database. Methods We downloaded and thoroughly reviewed the dental device-related AEs reported to MAUDE from January 01, 1996 – December 31, 2011. Results MAUDE received a total of 1,978,056 reports between January 01, 1996 and December 31, 2011. Among these reports, 28,046 (1.4 percent) AEs reports were associated with dental devices. Within the dental AE reports that had event type information, 17,261 reported injuries, 7,777 reported device malfunctions, and 66 reported deaths. Among the 66 entries classified as death reports, 52 actually reported a death in the description; the remaining were either misclassified or lacked sufficient information in the report to determine whether a death had occurred. 53.5 percent of the dental device associated AEs pertained to endosseous implants. Conclusion There is a plethora of devices used in dental care, and to achieve Element 1 of AHRQ’s Patient Safety Initiative, we must be able to monitor the safety of dental devices. While MAUDE is essentially the single source of this valuable information, our investigations led us to conclude that it currently has major limitations that prevent it from being the broad-based patient safety sentinel the profession requires. Practical Implications As potential contributors to MAUDE, dental care teams play a key role in improving the profession’s access to information about the safety of dental devices.

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Section: Discussionsupporting

confidence: 72%

The dangers of dental devices as reported in the Food and Drug Administration Manufacturer and User Facility Device Experience Database

Hebballi

Ramoni

Kalenderian

et al. 2015

The Journal of the American Dental Association

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“…4 At the same time, error is fundamental in health care, as our medical counterparts demonstrated over two decades ago, 5–8 and indeed errors (lapses, slips, mistakes 8,9 ) are commonplace in dentistry. 10–12 Several theories have been formulated to explain the mechanism of errors and how unchecked latent systemic factors, threats or failures (e.g., provider fatigue or inexperience, understaffing, poor supervision, faulty equipment, teamwork, vague organizational policies/procedures and poor safety culture) can lead to the occurrence of an adverse event (unintended harm or injury to a patient due to medical/dental management rather than their underlying condition 7, 9 ). 13,14 Some of these theories include the Swiss Cheese Model by James Reason 13 and the University of Texas Threat and Error Management Model by Robert Helmreich.…”

mentioning

confidence: 99%

“…With the exception of a few pioneer efforts, 12,21,23,24 the dental profession has essentially watched from the sidelines, as medicine moved towards developing patient safety initiatives. The time has now come for dentistry to commit to patient safety by systematically addressing adverse events and errors in dentistry.…”

mentioning

confidence: 99%

Lessons learned from dental patient safety case reports

Obadan

Ramoni²,

Kalenderian

2015

The Journal of the American Dental Association

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Background Errors are commonplace in dentistry, it is therefore our imperative as dental professionals to intercept them before they lead to an adverse event, and/or mitigate their effects when an adverse event occurs. This requires a systematic approach at both the profession-level, encapsulated in the Agency for Healthcare Research and Quality’s Patient Safety Initiative structure, as well as at the practice-level, where Crew Resource Management is a tested paradigm. Supporting patient safety at both the dental practice and profession levels relies on understanding the types and causes of errors, an area in which little is known. Methods A retrospective review of dental adverse events reported in the literature was performed. Electronic bibliographic databases were searched and data were extracted on background characteristics, incident description, case characteristics, clinic setting where adverse event originated, phase of patient care that adverse event was detected, proximal cause, type of patient harm, degree of harm and recovery actions. Results 182 publications (containing 270 cases) were identified through our search. Delayed and unnecessary treatment/disease progression after misdiagnosis was the largest type of harm reported. 24.4% of reviewed cases were reported to have experienced permanent harm. One of every ten case reports reviewed (11.1%) reported that the adverse event resulted in the death of the affected patient. Conclusions Published case reports provide a window into understanding the nature and extent of dental adverse events, but for as much as the findings revealed about adverse events, they also identified the need for more broad-based contributions to our collective body of knowledge about adverse events in the dental office and their causes. Practical Implications Siloed and incomplete contributions to our understanding of adverse events in the dental office are threats to dental patients’ safety.

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“…This paper summarizes the suggestions of academic and non-academic providers from across the dental community to enhance the adoption of DxTMs into the dental profession. As in medicine, DxTMs are necessary to assess treatment appropriateness, quality, and safety [ 20 , 21 , 22 ]. Moreover, the utilization of DxTMs facilitates the development of treatment planning skills, as it emphasizes the need for a diagnosis to drive treatment considerations [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

Dental Providers’ Perspectives on Diagnosis-Driven Dentistry: Strategies to Enhance Adoption of Dental Diagnostic Terminology

Obadan‐Udoh

Simon

Etolue

et al. 2017

IJERPH

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The routine use of standardized diagnostic terminologies (DxTMs) in dentistry has long been the subject of academic debate. This paper discusses the strategies suggested by a group of dental stakeholders to enhance the uptake of DxTMs. Through unstructured interviewing at the ‘Toward a Diagnosis-Driven Profession’ National Conference held on 19 March 2016 in Los Angeles, CA, USA participants were asked how enthusiastic they were about implementing and consistently using DxTMs at their work. They also brainstormed on strategies to improve the widespread use of DxTMs. Their responses are summarized by recursive abstraction and presented in themes. Conference participants were very enthusiastic about using a DxTM in their place of work. Participants enumerated several strategies to make DxTMs more appealing including: the use of mandates, a value proposition for providers, communication and education, and integration with EHRs and existing systems. All groups across the dental healthcare delivery spectrum will need to work together for the success of the widespread and consistent use of DxTMs. Understanding the provider perspective is however the most critical step in achieving this goal, as they are the group who will ultimately be saddled with the critical task of ensuring DxTM use at the point of care.

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An adverse event trigger tool in dentistry

Cited by 52 publications

References 11 publications

The dangers of dental devices as reported in the Food and Drug Administration Manufacturer and User Facility Device Experience Database

The dangers of dental devices as reported in the Food and Drug Administration Manufacturer and User Facility Device Experience Database

Lessons learned from dental patient safety case reports

Dental Providers’ Perspectives on Diagnosis-Driven Dentistry: Strategies to Enhance Adoption of Dental Diagnostic Terminology

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