Errors and adverse events in dentistry – a review

Abstract

As dental professionals we must change the way we think about error. By adopting a more positive, constructive approach, centred around analysing why errors happen, we can then accept our vulnerability and design systems and protocols to prevent errors from occurring. Errors are inextricably linked to human behaviour. Human factors in healthcare are concerned with ensuring patient safety through promoting efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. Essentially, this embraces standardization and involves examining and designing out error. Health Education England has highlighted education in ‘human factors’ as a priority workstream, however, there are many impediments to progress as system changes are slow and difficult to implement. This effectively means that, at present, it is up to individual practitioners to introduce the concept of human factors into their practices. A number of factors have been identified that are critical to reducing error, namely teamwork, communication, leadership and fatigue. Furthermore, a number of strategies have been implemented in secondary care to help reduce the risk of error, including effective leadership, specific policy and procedure, and monitoring and measuring compliance. The majority of the causes of error are related to human factors rather than technical ability or inadequate knowledge. This has major implications for primary care practice, as currently we are concentrating our professional development on the use of technology and our intellectual capabilities, rather than implementing education within, and the development of, human factors. It is our recommendation that human factors form part of our undergraduate teaching and core CPD (Continued Professional Development). CPD/Clinical Relevance: There needs to be a paradigm shift from a culture of blame to a just culture, where it is accepted that, despite our experience, character and talents, we are going to commit errors.

The impact of wrong‐site surgery on dental undergraduate teaching: a survey of UK dental schools

“…A move towards a more just culture of analysing systems rather than placing blame on the practitioner is vital to effecting positive change. 7 Failing to report errors and share learning have previously been identified as weaknesses in dental schools when compared to hospitals. 8 However, our survey highlights many dental schools have shown a proactive approach to patient safety.…”

“…6 Strategies to foster strong patient safety cultures have been advised as a way to minimise errors in health care. 7 In the United States, researchers noted a more positive patient safety culture within dental schools when compared to medical hospitals, although weaknesses in reporting events and organisational learning were identified in the school setting. 8 A recent study of a UK dental school identified that students had a good understanding and positive attitude towards patient safety.…”

Preventing Wrong Tooth Extraction in Primary Care Oral Surgery: LocSSIPs – Key Aspects of Implementation for Achieving and Sustaining Compliance

“…In-house competency frameworks for safety training can be advantageous, In the absence of readily-available, tailored, primary care team training in human factors (HF), responsibility falls on individual primary care practice owners to teach the basics of HF to the team. 9 Teaching human fallibility and the importance of a blame-free ethos is paramount in establishing a positive, sustained, patient safety culture. Simulations of clinical scenarios based around HF within the primary care environment in which staff work, can be simple, yet fulfilling training exercises on human, social and cognitive factors.…”

Preventing wrong tooth extraction in primary care oral surgery: developing local safety standards for invasive procedures (LocSSIPs)

“…6 Most medical errors are now attributed to HF rather than deficiencies in knowledge or technical ability. 7 The National Quality Board has created a concordat among healthcare organisations including NHS England, the Care Quality Commission, and Health Education England to take action and embed the principles of HF within our health service. 8 The National Advisory Board for Human Factors in Dentistry, established in 2018, recently published its position paper and aims to “raise awareness and understanding of the interplay of the multitude of factors called Human Factors that affect the provision of high-quality dental care leading to unforeseen outcomes compromising patient and team safety.” 9 They provide guidance on the steps dental teams can take to increase awareness of HF on patient and team safety, as well as clear definitions of patient safety terminology.…”