Recently a few interesting articles have been published to explore what are called never events or serious patient safety incidents that should not occur if appropriate preventive measures are implemented in dentistry. However, these articles and their analysis are all tailored to the U.K. The first article is titled “Patient safety in dentistry: development of a candidate ‘never event’ list for primary care” written by Black et al. in the British Dental Journal (vol. 222, no. 10, pp. 782-788, Published May 26, 2017). The second article is titled “Developing agreement on never events in primary care dentistry: an international eDelphi study,” written by Ensaldo-Carrasco et al. in the British Dental Journal (vol. 224, no. 9, pp. 733-740, Published May 11, 2018).
Prior to these articles there was not much clear research done on never events in dentistry. The best article was perhaps titled “Patient safety in dentistry – state of play as revealed by a national database of errors” written by Thusu et al. in the British Dental Journal (vol. 213, art. no. E3, 2012). This article explored data from a database of a national error-reporting system, the National Reporting and Learning System, from the Departments of Health in England and Wales. After some analysis a total number of 2,012 incident reports were explored. The researchers identified injuries (10.4%), medical emergencies (5.5%), adverse reactions (4%), inhalation or ingestion of foreign objects (3.6%), and wrong-tooth extractions (2%) as the most common errors of concern. It is also noteworthy that the lip was the most common site of injury and the most common procedure contributing to an injury was the use of a bur by a dentist.
In the article “Patient safety in dentistry: development of a candidate ‘never event’ list for primary care” the authors agreed that a never event must meet all of the following five conditions 1) is known to cause harm to a patient, or has the potential to do so, 2) is preventable by the healthcare professional, team or organisation, 3) can be clearly and precisely defined, 4) can be detected, and 5) is not an unlawful act. In the article the authors designed a study that included a review of empirical and grey literature to provide clues to the areas of dental practice where things may go wrong. Then the lead author attended educational events for dental practitioners to collect data on possible never events. Later two-half day workshops were held by the authors with different expert groups of dentists and educators. The never event definitional criteria was then applied by the expert groups to generate draft candidate never event statements. A first draft list of candidate never event statements for dentistry was developed and agreed, and sent by email to all participants to review. Eventually a risk matrix score was assigned to each candidate never event using a formula developed to asses the risk. The results eventually led to 27 distinct types of never events grouped across even themes. From this list of 27 possibilities, 11 were compliant with each of the five criteria for determining inclusion as a never event.
Eventually 9 never event statements related to dentistry were agreed and endorsed by the expert groups. These included 1) Prescribing a drug to a patient which has previously caused an adverse reaction or has potential to interact adversely with the patient’s current medication, 2) Not updating or checking a patient’s medical history prior to undertaking dental extractions, 3) Undertaking clinical procedures without taking adequate precautions to avoid potential for inhalation or ingestion of crowns or endodontic instruments, 4) Undertaking clinical care without having identified that the patient notes correspond to the patient presenting, 5) Omitting to check that treatment plans and radiographs concur with clinical findings before any treatment is commenced, 6) Failing to check that all referrals are sent and correspondence received from other consultants are checked to confirm treatment plans, 7) Carrying out decontamination procedures which are not in line with current guidance or inspection requirements, 8) Using decontamination equipment which has not been tested or maintained to guidance or manufacturers requirements, and 9) No regular checking system applied to ensure oxygen cylinders are available and that all recommended drugs are available and in date.
In the article titled ” Developing agreement on never events in primary care dentistry: an international eDelphi study,” the authors sought out to develop and achieve consensus on a list of never events with experts from around the world. In the first step of their study the authors developed an identification of candidate never events and a questionnaire using the Delph method developed by the US Research and Development Corporation. To accomplish this the authors reviewed primary care dentistry literature from Jan. 1994 to Jan. 2015 along with patient safety incident reports in the National Reporting and Learning System from 2005 to 2013. They also looked at an existing list of never events in hospital care to identify those believed to be transferable to dentistry. Once an initial candidate list of never events was identified the authors selected a group of experts from different countries and different backgrounds. This led to 41 experts asked to participate in the study with 32 agreeing to do so. Next, the authors sent emails with the questionnaire with never events to score. This included a first and a second round of a questionnaire. Of the 32 experts that did the first round 29 also did the second round. The experts reached a consensus on 23 out of 43 candidate never events.
This list of 23 never events includes in the routine assessment 1) Failure to register patient’s history of allergies to medication; in the pre-operative stage 1) Treatment provided to the wrong patient, 2) Failure to check patient´s identity before implementing a procedure, and 3) Failure to sterilise re-usable instruments; in the intraoperative stage 1) Wrong tooth extracted, 2) Use of non-sterilised re-useable instruments, 3) Patient’s eye injured due to the omission of using appropriate eye protection, 4) Administration of unlabelled cartridge of local anaesthetics, 5) Jaw fracture during implant placement due to poor treatment plan, 6) Jaw fracture during implant placement due to its incorrect placement, 7) Injection of sodium hypochlorite into surrounding structures during root canal treatment/irrigation, 8) Use of dental material in a patient with known history of allergy to the dental material used, 9) Re-use of disposable items, 10) Aspiration (inhalation) of foreign objects, 11) Use of non-disinfected equipment, 12) Re-use of damaged endodontic files, and 13) Injection of wrong aesthetic solution; and in the post-operative stage 1) Prescription of a drug to a patient with a known allergy to the drug, 2) Prescription of teratogenic drug to patients known to be pregnant, 3) Retained foreign objects after surgical procedures (excluding root canal procedures), 4) Incorrect medication prescribed to paediatric patients.
The authors noted that their study list of never events compared well for 10 of the 27 never events found by the article by Black et al. discussed above. They noted that the discrepancies could have arisen from the process to select the candidate never event lists and the selection of experts. I also see that the list by
Ensaldo-Carrasco et al. appears to have a few repetitions such as the sterilise re-usable instruments appearing in both the preoperative stage and the intraoperative stage. Even so the authors in Ensaldo-Carrasco et al. feel their study addresses methodological concerns in the study by Black et al.
By bettering understanding never events it is hoped that patient safety can be improved and can lead to future studies to further explore ways to help address patient safety incidents. It is also believed that implementing never events into incident reporting systems can ensure proper monitoring and the ability to learn from such incidents.