Preventing wrong tooth extraction: experience in development and implementation of an outpatient safety checklist

Saksena, A.; Pemberton, M. N.; Shaw, A.; Dickson, S.; Ashley, Martin

doi:10.1038/sj.bdj.2014.860

Cited by 52 publications

(30 citation statements)

References 13 publications

(11 reference statements)

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“…We used a free listing method 25 based upon previous studies aimed at developing inventories of medical issues. 26, 27 The FG interview guide (Appendix 1) ensured the fidelity of the interview structure between the six groups. The literature indicates that free Listing methods are designed to capture a saturated list of responses to a single question.…”

Section: Methodsmentioning

confidence: 99%

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How dental team members describe adverse events

Maramaldi¹,

Walji²,

White³

et al. 2016

The Journal of the American Dental Association

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Background There is increased recognition that patients suffer adverse events (AEs) or harm caused by treatments in dentistry, and little is known about how dental providers describe these events. Understanding how providers view AEs is essential to building a safer environment in dental practice. Methods Dental providers and domain experts were interviewed through focus groups and in-depth interviews and asked to identify the types of AEs that may occur in dental settings. Results The first order listing of the interview and focus group findings yielded 1,514 items that included both causes and AEs. 632 causes were coded into one of the eight categories of the Eindhoven classification. 882 AEs were coded into 12 categories of a newly developed dental AE classification. Inter-rater reliability was moderate among coders. The list was reanalyzed and duplicate items were removed leaving a total of 747 unique AEs and 540 causes. The most frequently identified AE types were “Aspiration/ingestion” at 14% (n=142), “Wrong-site, wrong-procedure, wrong-patient errors” at 13%, “Hard tissue damage” at 13%, and “Soft tissue damage” at 12%. Conclusions Dental providers identified a large and diverse list of AEs. These events ranged from “death due to cardiac arrest” to “jaw fatigue from lengthy procedures”. Practical Implications Identifying threats to patient safety is a key element of improving dental patient safety. An inventory of dental AEs underpins efforts to track, prevent, and mitigate these events.

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Section: Methodsmentioning

confidence: 99%

“…Building on previous research in dental patient safety, 19–27 our goal for this study was to contribute to Element 1 of the patient safety initiative by developing an inventory of AEs generated by interviewing dental team members.…”

Section: Introductionmentioning

confidence: 99%

How dental team members describe adverse events

Maramaldi¹,

Walji²,

White³

et al. 2016

The Journal of the American Dental Association

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“…We know that it continues to occur in dentistry but do not have accurate figures as to its frequency and volume. 3,12,13 Studies have indicated risk factors that contribute to its occurrence including miscommunication between clinicians within and between clinics, having multiple teeth for extraction, partially erupted teeth mimicking third molars, teeth with gross decay and time pressures. 14,15 In an attempt to reduce the risk of wrong tooth extraction occurring, strategies have been tried including educational programmes with various degrees of success.…”

Section: Wrong Tooth Extractionmentioning

confidence: 99%

“…In dentistry, experiences in the use of a surgical safety checklist to prevent wrong tooth extractions in dental hospital settings have been published. 3 In addition, checklists have been proposed more recently for use in endodontic treatment, for dental implant placement and in the early identification of malignancy presenting as a temporomandibular disorder. [18][19][20] This survey confirms the widespread use of checklists for oral surgical procedures in an out-patient setting in dental hospitals.…”

Section: Checklistsmentioning

confidence: 99%

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Surgical safety checklists and understanding of Never Events, in UK and Irish dental hospitals

Pemberton

2016

Br Dent J

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Aim To identify the procedures in dental hospitals where a surgical safety checklist is used and in addition, in England, to identify the understanding of hospitals regarding patient safety incidents requiring reporting as Never Events to NHS England.Method A self-completed questionnaire survey asking about the use of checklists was distributed to 16 dental hospitals associated with undergraduate dental schools in the UK and Ireland in the summer of 2015. For hospitals in England (10), additional questions regarding their understanding of incidents to be reported as Never Events were asked.Results Thirteen hospitals replied (8 in England). All use a surgical safety checklist in an operating theatre setting. Ten use a surgical safety checklist in an outpatient setting for the extraction of teeth. There is variable use of checklists for other procedures. The majority of English hospitals thought that the reporting of a 'Never Event' was required following wrong tooth extraction in whatever setting it occurred, including general dental practice.Conclusion Surgical safety checklists are increasingly used in dental hospitals, especially for oral surgery procedures. Beyond 'wrong tooth extraction', English dental hospitals have different understandings of what other oral and dental procedures require reporting as Never Events to NHS England.

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Effect of Systematic Physician Cross-checking on Reducing Adverse Events in the Emergency Department

et al. 2018

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IMPORTANCE Emergency departments (ED) are environments that are at high risk for medical errors. Previous studies suggested that the proportion of medical errors may decrease when more than 1 physician is involved.OBJECTIVE To reduce the proportion of medical errors by implementing systematic cross-checking between emergency physicians. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized crossover trial includes a random sample of 14 adult patients (age Ն18 years) per day during two 10-day period in 6 EDs (n = 1680 patients) in France.INTERVENTIONS Systematic cross-checking between emergency physicians, 3 times a day, which included a brief presentation of one physician's case to another, followed by the second physician's feedback to the first. MAIN OUTCOMES AND MEASURESMedical error in the ED, defined as an adverse event (either a near miss or a serious adverse event). The primary end point was identified using a 2-level error detection surveillance system, blinded to the strategy allocation. RESULTS Among the 1680 included patients (mean [SD] age, 57.5 [21.7] years), 144 (8.6%) had an adverse event. There were 54 adverse events among 840 patients (6.4%) in the cross-check group compared with 90 adverse events among 840 patients (10.7%) in the standard care group (relative risk reduction [RRR], 40% [95% CI, 12% to 59%]; absolute risk reduction [ARR], 4.3%; number needed to treat [NNT], 24). There was also a significant reduction rate of near misses (RRR, 47% [95% CI, 15% to 67%]; ARR, 2.7%; NNT, 37) but not of the rate of preventable serious adverse events (RRR, 29% [95% CI, −18% to 57%]; ARR, 1.2%; NNT, 83). CONCLUSIONS AND RELEVANCEThe implementation of systematic cross-checking between emergency physicians was associated with a significant reduction in adverse events, mainly driven by a reduction in near misses.

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Preventing wrong tooth extraction: experience in development and implementation of an outpatient safety checklist

Cited by 52 publications

References 13 publications

How dental team members describe adverse events

How dental team members describe adverse events

Surgical safety checklists and understanding of Never Events, in UK and Irish dental hospitals

Effect of Systematic Physician Cross-checking on Reducing Adverse Events in the Emergency Department

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