Patient safety incidents reported by Finnish dentists; results from an internet-based survey

Hiivala, Nora; Mussalo‐Rauhamaa, Helena; Murtomaa, Heikki

doi:10.3109/00016357.2013.764005

Cited by 25 publications

(39 citation statements)

References 16 publications

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“…Our results illustrate that most patients experienced temporary harm significant enough to require a transfer to the emergency room or hospitalization (24.1%), permanent harm (24.4%), intervention required to sustain life (6.7%) or resulted in death (11.1%). While these aggregate numbers may be an overrepresentation of the true prevalence by virtue of reporting bias inherent to our data source, studies from Finland 10 have estimated the prevalence of permanent harm due to dental adverse events as 13%. These estimates serve as a wake-up call for the profession to begin systematically addressing adverse events in dentistry.…”

Section: Discussionmentioning

confidence: 99%

“…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.…”

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confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

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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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“…También los resultados del presente trabajo demuestran que la población estudiantil desconoce la definición de los términos de atención segura al registrar en las evoluciones cada situación como un hallazgo sin denominación en la taxonomía, opuesto a lo reportado por Hiivala y colaboradores quienes publicaron los resultados de encuestas realizadas a odontólogos Finlandeses en el 2010 sobre la seguridad del paciente en los diferentes procedimientos odontológicos, encontrando que solo un tercio de los odontólogos reportó uno o más incidentes en su consulta en los últimos 12 meses, y al menos un quinto de encuestados habían presentado un evento adverso, y sólo un 16 % admitieron un casi evento adverso (26). Así, una vez tipificado en la Facultad de Odontología de la Pontificia Universidad Javeriana, de 929 historias evaluadas entre los años 2011-2012, solo un 5,7 % de los casos reportados representaron principalmente complicaciones (n: 18) (33,9 %) y evento adverso (n: 15) (26,3 %), no se identificaron casi evento adverso, por lo que se puede inferir que el reporte de eventos adversos clínicos quirúrgicos y no quirúrgicos es bajo, posiblemente asociado a una presión subyacente a medidas legales o señalamiento entre profesionales.…”

Section: Discussionunclassified

Características y prevalencia de los eventos adversos presentados en la Clínica del Posgrado de Periodoncia de la Facultad de Odontología de la Pontificia Universidad Javeriana durante el período 2011-2012

Gallego¹,

Vélez²,

Penagos

et al. 2017

Univ Odontol

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RESUMEN. Antecedentes: El aumento en la incidencia de los eventos adversos derivados de la práctica clínica a causa de un error potencialmente preveniblehan generado una preocupación por parte de la Organización Mundial de la Salud debido a su gran impacto en la salud del paciente conllevando a la necesidad de establecer medidas que garanticen la atención segura del paciente por parte de las instituciones educativas que proveen un servicio de salud. Propósito: identificar, caracterizar y documentar la frecuencia de los eventos adversos en el área de periodoncia, detectados en las historias clínicas de los pacientes que asistieron a la Clínica de Posgrado de Periodoncia de la Facultad de Odontología de la Pontificia Universidad Javeriana en el periodo de 2011- 2012. Métodos: estudio descriptivo, se analizaron 929 historias clínicas, para identificación y caracterización de eventos adversos en periodoncia, evaluando 3.886 procedimientos durante los años 2011 y 2012. Resultados: Los eventos adversos en periodoncia encontrados fueron 15 de 929 historias, dentro de los cuales los eventos adversos no clínicos prevenibles se observaron en un 9,43 % y evento adverso clínico prevenible en un 16,9 %, sin embargo, se detectó que de 1.738 procedimientos quirúrgicos solo 406 casos recibieron control posquirúrgico. Conclusión: La frecuencia observada de eventos adversos prevenibles en periodoncia indica una baja tasa de reporte y un subregistro de éstos a partir de la falencia en el registro de controles posquirúrgicos, siendo importante establecer mecanismos de reporte y seguimiento. ABSTRACT. Background: The increase of events adverse incidence as a result of preventable clinical practice errors calls the attention to the World Health Organization due to the enormous impact that these have in patients’ health. Therefore, it is mandatory to establish the measures that guarantee the patient safety on the part of educational institutions that provide health services. Purpose: To identify, typify, and determine the frequency of adverse events detected in the dental records of patients that attended the Postgraduate program of Periodontics at the Pontifical University during the period of 2011 and 2012. Methods: In order to identify, typify and determine the frequency of the adverse events in Periodontics 929 dental records were analyzed. About 3.886 periodontal procedures were evaluated during 2011 and 2012. Results: The adverse events in periodontics found were 15 from 929 dental records analyzed. Within which preventable non clinic adverse events were observed in 9,43 % and preventable clinic adverse events were in 16,9 %, however, it was detected that from 1.738 surgical procedures only 406 cases had follow-up. Conclusion: The frequency observed of preventable adverse events in Periodontics indicates a low rate report in the dental records. Consequently, it also indicates that there is underreport of the follow-up information during postoperative controls, being important to create mechanisms of report and follow-up.

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“…In addition, reporting of adverse events in dentistry is significantly low. [8][9][10][11][12] A previous analysis of NRLS data relating to dentistry also highlighted poor practice in reporting adverse events in dentistry. 9…”

Section: Discussionmentioning

confidence: 99%

“…It is recognised that patient safety incident reporting is particularly poor in dentistry compared with other healthcare settings. [8][9][10][11][12] Both NHS and Independent providers are obliged to report serious events, and there are stipulated guidelines regarding these events (including 'never events') clarifying the responsibility for all health care providers in their duty to report. Absence of a centralised and open reporting culture in dentistry means that we will not benefit from a learning culture and repeated errors compromising patient safety will continue to persist.…”

Section: Introductionmentioning

confidence: 99%

Review of never and serious events related to dentistry 2005–2014

Renton

Sabbah²

2016

Br Dent J

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Aims To review never and serious events related to dentistry between 2005-2014 in England.Methods Data from the National Reporting and Learning System (NRLS), with agreed data protection and intelligence governance, was used - snapshot view using the timeframe January 2005 to May 2014. The Strategic Executive Information System (STEIS) database was reported separately for 2012-2013 and 2013-2014. The free text elements from the database were analysed thematically and reclassified according to the nature of the patient safety incident (PSI).Results From the NRLS dataset, 32,263 patient safety events were reported between 1 January 2005 and 30 May 2014. Never events (NEs) from STEIS files were all wrong site extractions (WSS), reported separately for 2012-2013 and 2013-2014. The total number was 43.36 of the 43 PSIs were WSS involving: multiple extractions and bimodal age distribution (very young or over 60 years). Forty-seven percent of never events resulted in no harm, 20% low harm, 7% moderate harm, less than 1% severe harm and 23 deaths over this period (five of which were not related to dentistry). Serious harm and death risk factors included: care in an acute trust ward, peri oncological, reconstructive surgery (OMFS), patient age over 67 years with concurrent medical complexity (Ischaemic heart disease). Sixty percent of PSIs occurred in OS/OMFS in acute trust inpatients and 20% in primary care. From STEIS 2012-2013, 21 WSS were reported of which 50% occurred in oral surgery (OS) or oral and maxillofacial surgery (OMFS). The reported sites were 45% in operating theatre and 42% in dental surgery.Conclusion Incidences of iatrogenic harm to dental patients do occur but their reporting is not widely carried out. Improved awareness and training, simplifying the reporting systems improved non-punitive support by regulators would allow the improvement of patient safety in dental practise.

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Patient safety incidents reported by Finnish dentists; results from an internet-based survey

Cited by 25 publications

References 16 publications

Lessons learned from dental patient safety case reports

Lessons learned from dental patient safety case reports

Características y prevalencia de los eventos adversos presentados en la Clínica del Posgrado de Periodoncia de la Facultad de Odontología de la Pontificia Universidad Javeriana durante el período 2011-2012

Review of never and serious events related to dentistry 2005–2014

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