Patient safety incidents in dentomaxillofacial imaging: reported adverse events from Hospital District Helsinki and Uusimaa and the City of Helsinki during 2012–2017

Abstract

Objectives Our study aimed to reveal the frequency of patient safety incidents (PSI) in dentomaxillofacial radiology (DMFR), including their mitigating and contributing factors, to help recognize and thus better prevent these adverse events (AE) in the future. Methods Hospital District Helsinki and Uusimaa (HUS) and the City of Helsinki (HKI) use HaiPro, an anonymous web-based tool, for healthcare professionals to report PSI. Dentistry-related PSIs were evaluated individually to find any DMFR-related reports. Additionally, we searched the HaiPro-data using multiple dentistry- and DMFR-related keywords. We compartmentalized all DMFR-related PSI by their type and assessed their contributing factors, as well as their risk classification, severity, outcome, and possible corrective actions. Results In HUS and HKI, 43 of the 195,589 HaiPro-reports filed during 2012–2017 were DMFR-related. The most prevalent event type of DMFR-related PSIs was laboratory-, medical imaging-, or other patient examination-related events (33%). The second most common event type was defined as being related to flow or control of information (26%). For both of these event types, the most common contributing factors were shortcomings of communication and flow of information. Risk classification showed only one AE to be of moderate risk, and all others were perceived as irrelevant or minor. Conclusions PSI in DMFR are only rarely reported, and mostly, they are perceived of causing little or no harm. We detected a great difference in reporting activity between primary and secondary healthcare workers, but the underlaying causes remain unclear.