An adverse event trigger tool in dentistry

The Nature of Adverse Events in Dentistry

OBJECTIVES

Learning from clinical data on the subject of safety with regards to patient care in dentistry is still largely in its infancy. Current evidence does not provide epidemiological estimates on adverse events (AEs) associated with dental care. The goal of the dental practice study was to quantify and describe the nature and severity of harm experienced in association with dental care, and to assess for disparities in the prevalence of AEs.

METHODS

Through a multistaged sampling procedure, we conducted in-depth retrospective review of patients' dental and medical records.

RESULTS

We discovered an AE proportion of 1.4% (95% CI, 1.1% to 1.8). At least two-thirds of the detected AEs were preventable. Eight percent of patients who experienced harm due to a dental treatment presented only to their physician and not to the dentist where they originally received care.

CONCLUSIONS

Although most studies of AEs have focused on hospital settings, our results show that they also occur in ambulatory care settings. Extrapolating our data, annually, at least 3.3 million Americans experience harm in relation to outpatient dental care, of which over 2 million may be associated with an error.

PRACTICAL IMPLICATIONS

Measurement is foundational in enabling learning and improvement. A critical first step in preventing errors and iatrogenic harm in dentistry is to understand how often these safety incidents occur, what type of incidents occur, and what the consequences are in terms of patient suffering, and cost to the healthcare system.

The emergency department trigger tool: Multicenter trigger query validation

OBJECTIVES

We previously described derivation and validation of the emergency department trigger tool (EDTT) for adverse event (AE) detection. As the first step in our multicenter study of the tool, we validated our computerized screen for triggers against manual review, establishing our use of this automated process for selecting records to review for AEs.

METHODS

This is a retrospective observational study of visits to three urban, academic EDs over 18 months by patients ≥ 18 years old. We reviewed 912 records: 852 with at least one of 34 triggers found by the query and 60 records with none. Two first-level reviewers per site each manually screened for triggers. After completion, computerized query results were revealed, and reviewers could revise their findings. Second-level reviewers arbitrated discrepancies. We compare automated versus manual screening by positive and negative predictive values (PPVs, NPVs), present population trigger frequencies, proportions of records triggered, and how often manual ratings were changed to conform with the query.

RESULTS

Trigger frequencies ranged from common (>25%) to rare (1/1000) were comparable at U.S. sites and slightly lower at the Canadian site. Proportions of triggered records ranged from 31% to 49.4%. Overall query PPV was 95.4%; NPV was 99.2%. PPVs for individual trigger queries exceeded 90% for 28-31 triggers/site and NPVs were >90% for all but three triggers at one site. Inter-rater reliability was excellent, with disagreement on manual screening results less than 5% of the time. Overall, reviewers amended their findings 1.5% of the time when discordant with query findings, more often when the query was positive than when negative (47% vs. 23%).

CONCLUSIONS

The EDTT trigger query performed very well compared to manual review. With some expected variability, trigger frequencies were similar across sites and proportions of triggered records ranged 31%-49%. This demonstrates the feasibility and generalizability of implementing the EDTT query, providing a solid foundation for testing the triggers' utility in detecting AEs.

Breaking the error chain with SEE: cascade analysis of endodontic errors in clinical training

The ongoing endeavors to uncover the link between the prevalent errors in clinical endodontic training and undergraduate education are founded on tentative assumptions. This investigation was aimed at determining if cascade analysis can provide an understanding of the origins and causes of errors and if the sensitivity of student reports to the impact of errors on treatment outcomes can be established.In 2021, a group of investigators from the endodontics department concerned with clinical dental education launched the Study of Endodontic Errors (SEE). Sixty-six undergraduate dental students at one dental teaching hospital submitted anonymous narratives of problems they witnessed in their root canal treatment practices. The reports were examined to determine the sequence of events and the major errors. We kept track of the consequences of treatment outcomes, both as reported by students and as deduced by investigators.In 77% of the narratives, a chain of errors was recorded. The majority of the errors that took place were related to the working length or width of root canals. A substantial portion, 86%, of these errors could have been prevented through a deeper comprehension of the concepts that underlie working length and width. 75% of the errors that initiated cascades involved losing the correct working length. When asked whether the treatment outcome was compromised, students answered affirmatively in 16% of cases in which their narratives described compromised outcomes. Unacceptable outcomes necessitating re-treatment accounted for only 3% of student-reported consequences, but when investigator-inferred consequences were considered, the percentage more than doubled (7%).Cascade analysis of student error narratives is useful in understanding the triggering chain of events, but students provide insufficient information about how treatment outcomes are affected. Misconceptions about working length and width appear to play a significant role in the propagation of procedural errors.

Identifying Contributing Factors Associated With Dental Adverse Events Through a Pragmatic Electronic Health Record-Based Root Cause Analysis

OBJECTIVE

This study assessed contributing factors associated with dental adverse events (AEs).

METHODS

Seven electronic health record-based triggers were deployed identifying potential AEs at 2 dental institutions. From 4106 flagged charts, 2 reviewers examined 439 charts selected randomly to identify and classify AEs using our dental AE type and severity classification systems. Based on information captured in the electronic health record, we analyzed harmful AEs to assess potential contributing factors; harmful AEs were defined as those that resulted in temporary moderate to severe harm, required hospitalization, or resulted in permanent moderate to severe harm. We classified potential contributing factors according to (1) who was involved (person), (2) what were they doing (tasks), (3) what tools/technologies were they using (tools/technologies), (4) where did the event take place (environment), (5) what organizational conditions contributed to the event? (organization), (6) patient (including parents), and (7) professional-professional collaboration. A blinded panel of dental experts conducted a second review to confirm the presence of an AE.

RESULTS

Fifty-nine cases had 1 or more harmful AEs. Pain occurred most frequently (27.1%), followed by nerve injury (16.9%), hard tissue injury (15.2%), and soft tissue injury (15.2%). Forty percent of the cases were classified as "temporary not moderate to severe harm." Person (training, supervision, and fatigue) was the most common contributing factor (31.5%), followed by patient (noncompliance, unsafe practices at home, low health literacy, 17.1%), and professional-professional collaboration (15.3%).

CONCLUSIONS

Pain was the most common harmful AE identified. Person, patient, and professional-professional collaboration were the most frequently assessed factors associated with harmful AEs.

Adverse Events Related to Direct-To-Consumer Sequential Aligners-A Study of the MAUDE Database

Background-Direct-to-consumer (DTC) sequential aligners promote "teeth straightening" at a low cost and with added patient convenience. DTC sequential aligners have risen in popularity among the general public and sparked debate among dental professionals. Dental professionals argue that using these aligners without an in-person diagnosis and treatment planning protocol set by a licensed dentist or orthodontist may lead to adverse effects on teeth and surrounding structures. The objective of this study is to describe adverse clinical events associated with the use of DTC sequential aligners as reported in the Food and Drug Administration's Manufacturer and User Facility Device Experience (FDA MAUDE) database. Methods-We searched the MAUDE database from 1 January 2010 to 31 December 2020 for the product code of 'NXC' (sequential aligners). The year, type of adverse event, reporter occupation, and event description were noted. Results-651 reports associated with sequential aligners were found, of which 104 were related to DTC sequential aligners. Fifty-four adverse events were reported in 2019. From the event description, 41.3% comprised bite problems, 29.8% comprised orofacial pain, and 26.6% of patients had some form of periodontal sequelae. Furthermore, 69.2% of the patients followed up after an adverse event with a dentist not associated with DTC aligners. Conclusions-The use of DTC sequential aligners without dental supervision has led to oral health problems, as documented in the MAUDE database. Commonly reported adverse events include bite problems, pain, sensitivity, and periodontal disease, and some adverse events are irreversible.

Perceptions of Patient Safety Competence Using the Modified Version of the Health Professional Education in Patient Safety Survey (H-PEPSS) Instrument Among Dental Students in Riyadh, Saudi Arabia

AIM

To investigate dental students' self-reported confidence in learning about various domains of patient safety during their clinical training years.

METHODS

The Health Professional Education in Patient Safety Survey (H-PEPSS) was distributed to the fourth- and fifth-year undergraduate students, interns and postgraduate dental students. The survey explores how the seven domains of the Canadian Patient Safety Institute Safety Competencies Framework and wider cases of patient safety issues are presented in dental education, as well as participants' self-reported comfortability regarding revealing about patient safety issues. A comparison of the patient safety domains scores were assessed through learning scenarios (classroom and clinical), gender, level of study and type of institution.

RESULTS

Out of 409 participants, 359 undergraduate dental students and 131 postgraduate dental students responded to the survey. Irrespective of the groups, all dental students were most confident regarding their learning aspects about skills pertaining to clinical safety and effective communication and least confident in learning related to managing safety risks. All the patient safety factors irrespective of the scenario, scored above 75% and thus interpreted as good competence. Statistically significant differences were reported among the genders in the classroom scenario for learning about communicating effectively with the patients regarding patient safety issues (p < 0.05). Male dental students, undergraduates and those in the private institution were significantly less confident about recognizing and reporting to immediate risks in the clinical scenario compared to their respective counterparts (p < 0.05).

CONCLUSION

Based on the results, the dental students are quite confident with regard to the learning aspects of clinical patient safety, nevertheless, their confidence in learning certain patient safety aspects warrants further improvement. This implies a need to address the impact of regular interventions, extra motivation and repeated mentoring in both the classroom and clinical scenarios on improving dental students' confidence about patient safety.

Development of an Inventory of Dental Harms: Methods and Rationale

OBJECTIVES

While adverse events (AEs) are all too prevalent, their underlying causes are difficult to assess because they are often multifactorial. Standardizing the language of dental AEs is an important first step toward increasing patient safety for the dental patient.

METHODS

We followed a multimodal approach building a dental AE inventory, which included a literature review; review of the MAUDE database; a cross-sectional, self-administered patient survey; focus groups; interviews with providers and domain experts; and chart reviews.

RESULTS

One hundred eight unique allergy/toxicity/foreign body response, 70 aspiration/ingestion of foreign body, 70 infection, 52 wrong site/wrong patient/wrong procedure, 23 bleeding, 48 pain, 149 hard tissue injury, 127 soft tissue injury, 91 nerve injury, 171 other systemic complication, and 177 other orofacial complication were identified. Subtype AEs within the categories revealed that allergic reaction, aspiration, pain, and wrong procedure were the most common AEs identified among known (i.e., chart reviews) and hypothetical (i.e., interviews) sources.

CONCLUSIONS

Using a multimodal approach, a broad list of dental AEs was developed, in which the AEs were classed into 12 categories. Hard tissue injury was noted frequently during interviews and in actuality. Pain was the unexpected AE that was consistently identified with every modality used.

PRACTICAL IMPLICATIONS

Most AEs result in temporary harm with hard tissue injury being a common AE identified through interviews and in actuality through chart reviews. Acknowledging that AEs happen is an important step toward mitigating them and assuring quality of care for our patients.

Development of a Quality Improvement Dental Chart Review Training Program

INTRODUCTION

Chart review is central to understanding adverse events (AEs) in medicine. In this article, we describe the process and results of educating chart reviewers assigned to evaluate dental AEs.

METHODS

We developed a Web-based training program, "Dental Patient Safety Training," which uses both independent and consensus-based curricula, for identifying AEs recorded in electronic health records in the dental setting. Training included (1) didactic education, (2) skills training using videos and guided walkthroughs, (3) quizzes with feedback, and (4) hands-on learning exercises. In addition, novice reviewers were coached weekly during consensus review discussions. TeamExpert was composed of 2 experienced reviewers, and TeamNovice included 2 chart reviewers in training. McNemar test, interrater reliability, sensitivity, specificity, positive predictive value, and negative predictive value were calculated to compare accuracy rates on the identification of charts containing AEs at the start of training and 7 months after consensus building discussions between the 2 teams.

RESULTS

TeamNovice completed independent and consensus development training. Initial chart reviews were conducted on a shared set of charts (n = 51) followed by additional training including consensus building discussions. There was a marked improvement in overall percent agreement, prevalence and bias-adjusted κ correlation, and diagnostic measures (sensitivity, specificity, positive predictive value, and negative predictive value) of reviewed charts between both teams from the phase I training program to phase II consensus building.

CONCLUSIONS

This study detailed the process of training new chart reviewers and evaluating their performance. Our results suggest that standardized training and continuous coaching improves calibration between experts and trained chart reviewers.

Building Consensus for a Shared Definition of Adverse Events: A Case Study in the Profession of Dentistry

BACKGROUND

To achieve high-quality health care, adverse events (AEs) must be proactively recognized and mitigated. However, there is often ambiguity in applying guidelines and definitions. We describe the iterative calibration process needed to achieve a shared definition of AEs in dentistry. Our alignment process includes both independent and consensus building approaches.

OBJECTIVE

We explore the process of defining dental AEs and the steps necessary to achieve alignment across different care providers.

METHODS

Teams from 4 dental institutions across the United States iteratively reviewed patient records after identification of charts using an automated trigger tool. Calibration across teams was supported through negotiated definition of AEs and standardization of evidence provided in review. Interrater reliability was assessed using descriptive and κ statistics.

RESULTS

After 5 iterative cycles of calibration, the teams (n = 8 raters) identified 118 cases. The average percent agreement for AE determination was 82.2%. Furthermore, the average, pairwise prevalence and bias-adjusted κ (PABAK) was 57.5% (κ = 0.575) for determining AE presence. The average percent agreement for categorization of the AE type was 78.5%, whereas the PABAK was 48.8%. Lastly, the average percent agreement for categorization of AE severity was 82.2% and the corresponding PABAK was 71.7%.

CONCLUSIONS

Successful calibration across reviewers is possible after consensus building procedures. Higher levels of agreement were found when categorizing severity (of identified events) rather than the events themselves. Our results demonstrate the need for collaborative procedures as well as training for the identification and severity rating of AEs.

Burnout, Engagement, and Dental Errors Among U.S. Dentists

BACKGROUND

Errors can happen during patient care, and some result in harm to the patient. Work place stress has been well established in dentistry, but its relation with errors in the delivery of patient care is less understood. The authors evaluated the relationship between burnout, work engagement, and self-reported dental errors among American dentists.

METHODS

From May to August 2016, a national sample of American Dental Association member dentists were sent a validated, electronic survey assessing their levels of burnout, work engagement, and dental errors.

RESULTS

Of the 391 responding dentists, 46.1% reported concern that they had made a dental error in the last 6 months, 12.1% of the dentists were informed by dental staff that they may have committed an error in the last 6 months, 16% were concerned that a malpractice lawsuit would be filed against them, and 3.6% were actively involved in a malpractice lawsuit. In the adjusted analysis, multivariate logistic regression showed that dentists with either high burnout risk were more likely to report concern over a perceived error within the last 6 months.

CONCLUSIONS

The results suggest that dental provider burnout is potentially a key predictor of reporting perceived dental errors. It is imperative that the dental profession continue to study the effects of work-related stress, develop professional practices that decrease burnout, and reduce errors.

PRACTICAL IMPLICATIONS

Efforts that minimize the potential for burnout may help reduce the occurrence of errors and improve the quality of care provided to dental patients.

Multicenter Test of an Emergency Department Trigger Tool for Detecting Adverse Events

OBJECTIVES

Traditional approaches to safety and quality screening in the emergency department (ED) are porous and low yield for identifying adverse events (AEs). A better approach may be in the use of trigger tool methodology. We recently developed a novel ED trigger tool using a multidisciplinary, multicenter approach. We conducted a multicenter test of this tool and assess its performance.

METHODS

In design and participants, we studied the ED trigger tool for a 13-month period at four EDs. All patients 18 years and older with Emergency Severity Index acuity levels of 1 to 3 seen by a provider were eligible. Reviewers completed standardized training modules. Each site reviewed 50 randomly selected visits per month. A first-level reviewer screened for presence of predefined triggers (findings that increase the probability of an AE). If no trigger is present, the review is deemed complete. When present, a trigger prompts an in-depth review for an AE. Any event identified is assigned a level of harm using the Medication Event Reporting and Prevention (MERP) Index, ranging from a near miss (A) to patient death (I). Events are noted as present on arrival or in the ED, an act of commission or omission, and are assigned one of four event categories. A second-level physician performs a confirmatory review of all AEs and independently reviews 10% of cases to estimate the false-negative rate. All AEs or potential AEs were reviewed in monthly group calls for consensus on findings. The primary outcome is the proportion of visits in which an AE is identified, overall and by site. Secondary outcomes include categories of events, distribution of harm ratings, and association of AEs with sociodemographic and clinical factors and triggers. We present sociodemographic data and details about AEs and results of logistic regression for associations of AEs with of triggers, sociodemographics, and clinical variables.

RESULTS

We captured 2594 visits that are representative, within site, of their patient population. Overall, the sample is 64% white, 54% female, and with a mean age of 51. Variability is observed between sites for age, race, and insurance, but not sex. A total of 240 events were identified in 228 visits (8.8%) of which 53.3% were present on arrival, 19.7% were acts of omission, and 44.6% were medication-related, with some variability across sites. A MERP F score (contributing to need for admission, higher level of care, or prolonged hospitalization) was the most common severity level (35.4% of events). Overall, 185 (77.1%) of 240 events involved patient harm (MERP level ≥ E), affecting 175 visits (6.7%). Triggers were present in 951 visits (36.6%). Presence of any trigger was strongly associated with an AE (adjusted odds ratio = 4.6, 95% confidence interval = 3.2-6.6). Ten triggers were individually associated with AEs (adjusted odds ratio = 2.1-7.7). Variability was observed across sites in individual trigger associations, event rates, and categories, but not in severity ratings of events. The overall false-negative rate was 6.1%.

CONCLUSIONS

The trigger tool approach was successful in identifying meaningful events. The ED trigger tool seems to be a promising approach for identifying all-cause harm in the ED.

Patient-Reported Dental Safety Events: A South African Perspective

OBJECTIVES

In recent years, there has been an increase in research studies highlighting patients' experiences of adverse events (AEs) as well as the role of patients in promoting safety. The primary goal of the study was to assess the prevalence of dental AEs (DAEs) among dental patients in South Africa and its associated factors. The integration of the patient perspective into dental patient safety research will enhance our collective understanding of DAEs.

METHODS

We conducted a cross-sectional study of adult patients at a large dental academic institution in South Africa from May to June 2015, evaluating their previous experiences of DAEs at any dental clinic in South Africa. Descriptive statistics and bivariate and multivariate analyses were performed to identify the factors associated with an increased likelihood of experiencing a DAE.

RESULTS

A total of 440 questionnaires were returned during the 6-week study period (response rate = 97.8%). Overall, 45.5% of participants reported experiencing one or more DAEs. Two hundred participants reported a total of 717 DAEs giving us a lifetime prevalence of 1.6 DAEs per respondent. Our results suggest that respondents who were younger (18-24 y), from high-income families (>R150,000 or US $9200), dissatisfied with their last dental visit and oral health had an increased likelihood of reporting a previous experience of a DAE.

CONCLUSIONS

This study provides an insight into the nature of information that can be gleaned from dental patients regarding safety and helps lay the foundation for patient involvement in patient safety reporting.

Classifying Adverse Events in the Dental Office

BACKGROUND

Dentists strive to provide safe and effective oral healthcare. However, some patients may encounter an adverse event (AE) defined as "unnecessary harm due to dental treatment." In this research, we propose and evaluate two systems for categorizing the type and severity of AEs encountered at the dental office.

METHODS

Several existing medical AE type and severity classification systems were reviewed and adapted for dentistry. Using data collected in previous work, two initial dental AE type and severity classification systems were developed. Eight independent reviewers performed focused chart reviews, and AEs identified were used to evaluate and modify these newly developed classifications.

RESULTS

A total of 958 charts were independently reviewed. Among the reviewed charts, 118 prospective AEs were found and 101 (85.6%) were verified as AEs through a consensus process. At the end of the study, a final AE type classification comprising 12 categories, and an AE severity classification comprising 7 categories emerged. Pain and infection were the most common AE types representing 73% of the cases reviewed (56% and 17%, respectively) and 88% were found to cause temporary, moderate to severe harm to the patient.

CONCLUSIONS

Adverse events found during the chart review process were successfully classified using the novel dental AE type and severity classifications. Understanding the type of AEs and their severity are important steps if we are to learn from and prevent patient harm in the dental office.

Patient Safety Incidents and Adverse Events in Ambulatory Dental Care: A Systematic Scoping Review

BACKGROUND

There have been efforts to understand the epidemiology of iatrogenic harm in hospitals and primary care and to improve the safety of care provision. There has in contrast been very limited progress in relation to the safety of ambulatory dental care.

OBJECTIVES

To provide a comprehensive overview of the range and frequencies of existing evidence on patient safety incidents and adverse events in ambulatory dentistry.

METHODS

We searched MEDLINE and EMBASE for articles reporting events that could have or did result in unnecessary harm in ambulatory dental care. We extracted and synthesized data on the types and frequencies of patient safety incidents and adverse events.

RESULTS

Forty articles were included. We found that the frequencies varied very widely between studies; this reflected differences in definitions, populations studied, and sampling strategies. The main 5 PSIs we identified were errors in diagnosis and examination, treatment planning, communication, procedural errors, and the accidental ingestion or inhalation of foreign objects. However, little attention was paid to wider organizational issues.

CONCLUSIONS

Patient safety research in dentistry is immature because current evidence cannot provide reliable estimates on the frequency of patient safety incidents in ambulatory dental care or the associated disease burden. Well-designed epidemiological investigations are needed that also investigate contributory factors.

The Emergency Department Trigger Tool: Validation and Testing to Optimize Yield

OBJECTIVE

Recognized as a premier approach for adverse event (AE) detection, trigger tools have been developed for multiple clinical settings outside the emergency department (ED). We recently derived and tested an ED trigger tool (EDTT) with enhanced features for high-yield detection of harm, consisting of 30 triggers associated with AEs. In this study, we validate the EDTT in an independent sample and compare record selection approaches to optimize yield for quality improvement.

METHODS

This is a retrospective observational study using data from 13 months of visits to an urban, academic ED by patients aged ≥ 18 years (92,859 records). We conducted standard two-tiered trigger tool reviews on an independent validation sample of 3,724 records with at least one of the 30 triggers found associated with AEs in our previous derivation sample (N = 1,786). We also tested three new candidate triggers and reviewed 72 records with no triggers for comparison purposes. We compare derivation and validation samples on: 1) triggers showing persistent associations with AEs, 2) AE yield (AEs detected/records reviewed), and 3) representativeness of AE types detected. We use bivariate associations of triggers with AEs as the basis for trigger selection. We then use multivariable modeling in the combined derivation and validation samples to determine AE risk scores using trigger weights. This allows us to predict occurrence of AEs and derive population prevalence estimates. Finally, we compare yield for detection of AEs under three record selection strategies (random selection, trigger counts, weighted trigger counts).

RESULTS

Twenty-four of the 30 triggers were confirmed to be associated with AEs on bivariate testing. Three previously marginal triggers and two of three new candidate triggers were also found to be associated with AEs. The presence of any of these 29 triggers was associated with an AE rate of 10% in our selected sample (compared to 1.1% for none, p < 0.001). The risk of an AE increased with number of triggers. Combining data from both phases, we identified 461 AEs in 429 unique visits in 5,582 records reviewed. Our multivariable model (which emphasized parsimony) retained 12 triggers with a ROC AUC of 82% in both samples. Selecting records for review based on number of triggers improves yield to 14% for 4+ triggers (top 10% of visits) and to 28% for 8+ (top 1%). A weighted trigger count has corresponding yields of 18 and 38%. The method for selecting records for review did not appear to affect event-type representativeness, with similar distributions of event types and severities detected.

CONCLUSIONS

In this single-site study of the EDTT we observed high levels of validity in trigger selection, yield, and representativeness of AEs, with yields that are superior to estimates for traditional approaches to AE detection. Record selection using weighted triggers outperforms a trigger count threshold approach and far outperforms random sampling from records with at least one trigger. The EDTT is a promising efficient and high-yield approach for detecting all-cause harm to guide quality improvement efforts in the ED.

Patient safety in dental care: an integrative review

Adverse events pose a serious problem for quality of healthcare. Dental practice is eminently invasive and involves close and routine contact with secretions; as such, it is potentially prone to the occurrence of adverse events. Various patient safety studies have been developed in the last two decades, but mostly in the hospital setting due to the organizational complexity, severity of the cases, and diversity and specificity of the procedures. The objective was to identify and explore studies on patient safety in Dentistry. An integrative literature review was performed in MEDLINE via PubMed, Scopus via Portal Capes, and the Regional Portal of the Virtual Health Library, using the terms patient safety and dentistry in English, Spanish, and Portuguese, starting in 2000. The research cycle in patient safety was used, as proposed by the World Health Organization to classify studies. We analyzed 91 articles. The most common adverse events were allergies, infections, diagnostic delay or failure, and technical error. Measures to mitigate the problem highlight the need to improve communications, encourage reporting, and search for tools to assist the management of care. The authors found a lack of studies on implementation and assessment of the impact of proposals for improvement. Dentistry has made progress in patient safety but still needs to transpose the results into practice, where efforts are crucial to prevent adverse events.

Are Dental Patients Concerned About Safety? An Exploratory Study

OBJECTIVES

This study addresses a gap in the literature regarding dental patients' perceptions about safety at the dental office and their attitudes toward reporting safety concerns and experiences.

METHODS

We conducted a cross-sectional study with adult dental patients at an academic dental institution over a 6-week study period. A 16-item questionnaire was distributed to the patients to assess (1) past safety concerns and experiences during dental visits; (2) factors affecting the future reporting of safety concerns and experiences; (3) overall concern about safety at the dental office; (4) overall perceptions that patients should report of safety concerns or experiences to dental providers and staff.

RESULTS

A majority (63.5%) of dental patients were concerned about safety at the dental office, although only one-third of them shared their past safety concerns or experiences with their dental providers or clinic staff. Irrespective of their past experiences, most patients (96.9%) believed that patients should report any safety concerns or experiences to the clinic. Being female, highly educated, and having poor oral health were associated with a decreased overall perception that patients should report safety concerns and experiences to dental care providers and staff.

CONCLUSIONS

Our findings suggest that dental patients are concerned about safety and can be valuable sources of data, when adequately engaged. The current level of patient reporting of safety concerns and/or experiences to clinic staff or care providers is not optimal for learning and improvement.

PRACTICAL IMPLICATIONS

Better patient engagement in safety activities will potentially increase our collective understanding of threats to safety. Therefore, dental clinics need to encourage patients to speak up about their safety concerns or experiences.

Adverse Events Present on Arrival to the Emergency Department: The ED as a Dual Safety Net

BACKGROUND

The emergency department (ED) is the natural venue for the provision of acute unscheduled care. However, little is known about the nature and proportion of this care that goes to addressing adverse events (AEs)-physical injury to a patient due to health care that requires some intervention-that are present on arrival (POA) to the ED. Described here are AEs that are POA, and population prevalence estimates for these events.

METHODS

This retrospective observational study tested the ED Trigger Tool, using data from an urban academic medical center. Patients aged ≥18 completing an ED visit were eligible (N = 92,859). A total of 5,582 visits with triggers (findings that increase the likelihood of an AE) were reviewed using the two-tier trigger approach. AEs were categorized by severity, type, and whether they were POA. POA AEs, and sociodemographic and trigger associations with AEs are described.

RESULTS

Of 1,181 AEs identified, 718 (60.8%) were POA to the ED. Patients with POA AEs were more often white (51.1% vs. 39.7%, p < 0.001) and older (median age 62 vs. 50, p < 0.001). The majority of POA AEs were medication-related and patient care-related events. In the population at this center, POA AEs account for an estimated 7.6% of ED visits (95% confidence interval = 6.9%-8.2%).

CONCLUSION

In this single-center study, the majority of AEs detected using the ED Trigger Tool were POA. These findings highlight the importance of the ED as a safety net for harm occurring across the health system.

Finding Dental Harm to Patients through Electronic Health Record-Based Triggers

BACKGROUND

Patients may be inadvertently harmed while undergoing dental treatments. To improve care, we must first determine the types and frequency of harms that patients experience, but identifying cases of harm is not always straightforward for dental practices. Mining data from electronic health records is a promising means of efficiently detecting possible adverse events (AEs).

METHODS

We developed 7 electronic triggers (electronic health record based) to flag patient charts that contain distinct events common to AEs. These electronic charts were then manually reviewed to identify AEs.

RESULTS

Of the 1,885 charts reviewed, 16.2% contained an AE. The positive predictive value of the triggers ranged from a high of 0.23 for the 2 best-performing triggers (failed implants and postsurgical complications) to 0.09 for the lowest-performing triggers. The most common types of AEs found were pain (27.5%), hard tissue (14.8%), soft tissue (14.8%), and nerve injuries (13.3%). Most AEs were classified as temporary harm (89.2%). Permanent harm was present in 9.6% of the AEs, and 1.2% required transfer to an emergency room.

CONCLUSION

By developing these triggers and a process to identify harm, we can now start measuring AEs, which is the first step to mitigating harm in the future.

KNOWLEDGE TRANSFER STATEMENT

A retrospective review of patients' health records is a useful approach for systematically identifying and measuring harm. Rather than random chart reviews, electronic health record-based dental trigger tools are an effective approach for practices to identify patient harm. Measurement is one of the first steps in improving the safety and quality of care delivered.

The Emergency Department Trigger Tool: A Novel Approach to Screening for Quality and Safety Events

STUDY OBJECTIVE

Trigger tools improve surveillance for harm by focusing reviews on records with "triggers" whose presence increases the likelihood of an adverse event. We refine and automate a previously developed emergency department (ED) trigger tool and present record selection strategies to further optimize yield.

METHODS

We specified 97 triggers for extraction from our electronic medical record, identifying 76,894 ED visits with greater than or equal to 1 trigger. We reviewed 1,726 records with greater than or equal to 1 trigger, following a standard trigger tool review process. We validated query performance against manual review and evaluated individual triggers, retaining only those associated with adverse events in the ED. We explored 2 approaches to enhance record selection: on number of triggers present and using trigger weights derived with least absolute shrinkage and selection operator logistic regression.

RESULTS

The automated query performed well compared with manual review (sensitivity >70% for 80 triggers; specificity >92% for all). Review yielded 374 adverse events (21.6 adverse events per 100 records). Thirty triggers were associated with risk of harm in the ED. An estimated 10.3% of records with greater than 1 of these triggers would include an adverse event in the ED. Selecting only records with greater than or equal to 4 or greater than or equal to 9 triggers improves yield to 17% and 34.8%, respectively, whereas use of least absolute shrinkage and selection operator trigger weighting enhances the yield to as high as 52%.

CONCLUSION

The ED trigger tool is a promising approach to improve yield, scope, and efficiency of review for all-cause harm in emergency medicine. Beginning with a broad set of candidate triggers, we validated a computerized query that eliminates the need for manual screening for triggers and identified a refined set of triggers associated with adverse events in the ED. Review efficiency can be further enhanced with enhanced record selection.

Critical Review, Development, and Testing of a Taxonomy for Adverse Events and Near Misses in the Emergency Department

OBJECTIVES

An adverse event (AE) is a physical harm experienced by a patient due to health care, requiring intervention. Describing and categorizing AEs is important for quality and safety assessment and identifying areas for improvement. Safety science suggests that improvement efforts should focus on preventing and mitigating harm rather than on error, which is commonplace but infrequently leads to AEs. Most taxonomies fail to describe harm experienced by patients (e.g., hypoxia, hemorrhage, anaphylaxis), focusing instead on errors, and use categorizations that are too broad to be useful (e.g., "communication error"). We set out to create a patient-centered, emergency department (ED)-specific framework for describing AEs and near misses to advance quality and safety in the acute care setting.

METHODS

We performed a critical review of existing taxonomies of harm, evaluating their applicability to the ED. We identified and adopted a classification framework and developed a taxonomy using an iterative process categorizing approximately 600 previously identified AEs and near misses. We reviewed this taxonomy with collaborators at four medical centers, receiving feedback and providing clarification. We then disseminated a set of representative scenarios for these safety experts to categorize independently using the taxonomy. We calculated interrater reliability and performance compared to our criterion standard.

RESULTS

Our search identified candidate taxonomies for detailed review. We selected the Adventist Health Systems AE taxonomy and modified this for use in the ED, adopting a framework of categories, subcategories, and up to three modifiers to further describe events. On testing, overall reviewer agreement with the criterion standard was 92% at the category level and 88% at the subcategory level. Three of the four raters concurred in 55 of 59 scenarios (93%) and all four concurred in 46 of 59 scenarios (78%). At the subcategory level, there was complete agreement in 40 of 59 (68%) scenarios and majority agreement in 55 of 59 instances (93%). Performance of individual raters ranged from very good (88%, 52/59) to near perfect (98%, 58/59) at the main category level.

CONCLUSIONS

We developed a taxonomy of AEs and near misses for the ED, modified from an existing framework. Testing of the tool with minimal training yielded high performance and good inter-rater reliability. This taxonomy can be adapted and modified by EDs seeking to enhance their quality and safety reviews and characterize harm occurring in their EDs for quality improvement purposes.

Improving Oral-Systemic Healthcare through the Interoperability of Electronic Medical and Dental Records: An Exploratory Study

OBJECTIVES

Electronic health records (EHRs) are rarely shared among medical and dental providers. The purpose of this study was to assess current information sharing and the value of improved electronic information sharing among physicians and dentists in Germany and the United States.

MATERIALS AND METHODS

A survey was validated and distributed electronically to physicians and dentists at four academic medical centers. Respondents were asked anonymously about EHR use and the medical and dental information most valuable to their practice.

RESULTS

There were 118 responses, a response rate of 23.2%. The majority (63.9%) of respondents were dentists and the remainder were physicians. Most respondents (66.3%) rated the importance of sharing information an 8 or above on a 1-to-10 Likert scale. Dentists rated the importance of sharing clinical information significantly higher than physicians (p = 0.0033). Most (68.5%) providers could recall an instance when access to medical or dental information would have improved patient care. Dentists were significantly more likely to report this than physicians (p = 0.008).

CONCLUSION

Physicians would value a standardized measure of "oral health" in their EHR. Dentists were less likely to find specific medical diagnostic test results of value. Both dentists and physicians agreed that oral-systemic health was important; interoperable EHRs could facilitate information transfer between providers and enhance research on oral-systemic health connections. Both dentists and physicians believed that an interoperable EHR would be useful to practice, but desired information was different between these groups. Refinement of the information needed for shared practice is required.

Dentists' perceptions of smart phone use in the clinical environment

Objective

To determine the use of smart phones in clinical practice and to determine the perceived impact on patient safety.

Study design

A closed questionnaire survey with an exploratory open question.

Setting, materials and methods

A questionnaire was sent to a sample of 216 delegates that have attended courses provided by an education provider in the North West of England between 2015–2017.

Results

There was a response rate of 49.5% which represented 107 returned questionnaires. The mean year of qualification is 2008. Of the respondents,105 were general dental practitioners, and two were hospital based dentists. Of the respondents, 82.2% had their smart phone in surgery, and of these 88% had the smart phone on silent, with the respondents on average receiving three texts, four emails and one call each session. Of the respondents, 40.9% were not aware that they received a text, 53.4% an email, and 37.5% a telephone call. Whilst 50.1% responded, in some way, to a text, 46.6% to an email and 62.5% to a telephone call. Of the respondents, 61.7% think that having a phone in the surgery is a distraction. Of the respondents, 20.7% stated that smart phones should not be allowed in the surgery under any circumstance, whilst 24.1% stated that they should be allowed if on silent and out of view, and 16.4% allowed their use but not in front of patients.

Conclusions

Eighty-eight percent of respondents had their smart phone with them in the surgery, with 61.7% reporting it to be a distraction from their clinical duties. It is our recommendation that each clinic has a protocol or policy that governs the use of smart phones focusing on patient safety.

Feasibility of Electronic Health Record-Based Triggers in Detecting Dental Adverse Events

BACKGROUND

We can now quantify and characterize the harm patients suffer in the dental chair by mining data from electronic health records (EHRs). Most dental institutions currently deploy a random audit of charts using locally developed definitions to identify such patient safety incidents. Instead, selection of patient charts using triggers and assessment through calibrated reviewers may more efficiently identify dental adverse events (AEs).

OBJECTIVE

Our goal was to develop and test EHR-based triggers at four academic institutions and find dental AEs, defined as moderate or severe physical harm due to dental treatment.

METHODS

We used an iterative and consensus-based process to develop 11 EHR-based triggers to identify dental AEs. Two dental experts at each institution independently reviewed a sample of triggered charts using a common AE definition and classification system. An expert panel provided a second level of review to confirm AEs identified by sites reviewers. We calculated the performance of each trigger and identified strategies for improvement.

RESULTS

A total of 100 AEs were identified by 10 of the 11 triggers. In 57% of the cases, pain was the most common AE identified, followed by infection and hard tissue damage. Positive predictive value (PPV) for the triggers ranged from 0 to 0.29. The best performing triggers were those developed to identify infections (PPV = 0.29), allergies (PPV = 0.23), failed implants (PPV = 0.21), and nerve injuries (PPV = 0.19). Most AEs (90%) were categorized as temporary moderate-to-severe harm (E2) and the remainder as permanent moderate-to-severe harm (G2).

CONCLUSION

EHR-based triggers are a promising approach to unearth AEs among dental patients compared with a manual audit of random charts. Data in dental EHRs appear to be sufficiently structured to allow the use of triggers. Pain was the most common AE type followed by infection and hard tissue damage.

Clinical Dental Faculty Members' Perceptions of Diagnostic Errors and How to Avoid Them

Diagnostic errors are increasingly recognized as a source of preventable harm in medicine, yet little is known about their occurrence in dentistry. The aim of this study was to gain a deeper understanding of clinical dental faculty members' perceptions of diagnostic errors, types of errors that may occur, and possible contributing factors. The authors conducted semi-structured interviews with ten domain experts at one U.S. dental school in May-August 2016 about their perceptions of diagnostic errors and their causes. The interviews were analyzed using an inductive process to identify themes and key findings. The results showed that the participants varied in their definitions of diagnostic errors. While all identified missed diagnosis and wrong diagnosis, only four participants perceived that a delay in diagnosis was a diagnostic error. Some participants perceived that an error occurs only when the choice of treatment leads to harm. Contributing factors associated with diagnostic errors included the knowledge and skills of the dentist, not taking adequate time, lack of communication among colleagues, and cognitive biases such as premature closure based on previous experience. Strategies suggested by the participants to prevent these errors were taking adequate time when investigating a case, forming study groups, increasing communication, and putting more emphasis on differential diagnosis. These interviews revealed differing perceptions of dental diagnostic errors among clinical dental faculty members. To address the variations, the authors recommend adopting shared language developed by the medical profession to increase understanding.

Development of a 'ready-to-use' tool that includes preventability, for the assessment of adverse drug events in oncology

Background Adverse drug events (ADEs) occur frequently in oncology and justify continuous assessment and monitoring. There are several methods for detecting them, but the trigger tool method seems the most appropriate. Although a generic tool exists, its use for ADEs in oncology has not been convincing. The development of a focused version is therefore necessary. Objective To provide an oncology-focused trigger tool that evaluates the prevalence, harm, and preventability in a standardised method for pragmatic use in ADE surveillance. Setting Hospitals with cancer care in France. Method The tool has been constructed in two steps: (1) constitution of an oncology-centred list of ADEs; 30 pharmacists/practitioners in cancer care from nine hospitals selected a list of ADEs using a method of agreement adapted from the RAND/UCLA Appropriateness Method; and (2) construction of three standardised dimensions for the characterisation of each ADE (including causality, severity, and preventability). Main outcome measure The main outcome measure was validation of the tool, including preventability criteria. Results The tool is composed of a final list of 15 ADEs. For each ADE, a 'reviewer form' has been designed and validated by the panel. It comprises (1) the trigger(s), (2) flowcharts to guide the reviewer, (3) criteria for grading harm, and (4) a standardised assessment of preventability with 6-14 closed sentences for each ADE in terms of therapeutic management and/or prevention of side-effects. Conclusion A complete 'ready-to-use' tool for ADE monitoring in oncology has been developed that allows the assessment of three standardised dimensions.

Proposal of a trigger tool to assess adverse events in dental care

The aim of this study was to propose a trigger tool for research of adverse events in outpatient dentistry in Brazil. The tool was elaborated in two stages: (i) to build a preliminary set of triggers, a literature review was conducted to identify the composition of trigger tools used in other areas of health and the principal adverse events found in dentistry; (ii) to validate the preliminarily constructed triggers a panel of experts was organized using the modified Delphi method. Fourteen triggers were elaborated in a tool with explicit criteria to identify potential adverse events in dental care, essential for retrospective patient chart reviews. Studies on patient safety in dental care are still incipient when compared to other areas of health care. This study intended to contribute to the research in this field. The contribution by the literature and guidance from the expert panel allowed elaborating a set of triggers to detect adverse events in dental care, but additional studies are needed to test the instrument's validity.

Dentists Survey on Adverse Events During Their Clinical Training

BACKGROUND

Adverse events (AEs) begin challenging the safe practice of dentistry early when students start treating patients at dental school. We assessed the frequency with which dentists caused common AEs during their undergraduate clinical training.

METHODS

A convenience sample of dentists, graduated from more than 34 dental schools in Mexico and other Spanish speaking countries, answered a confidential, self-administered questionnaire with closed-format questions on common AEs they caused and their active errors that could have led to AEs in the teaching clinics.

RESULTS

Of 207 participants, 80% had graduated recently. As undergraduates, 79% caused AEs; 38% admitted to causing one adverse event, 41% to causing two or more, and 36% committed active errors that could have hurt patients. No significant associations between AEs and sex or type of school were observed.

CONCLUSIONS

The results indicate that dental students caused AEs or committed errors that placed patients at risk, during their clinical training.

PRACTICAL IMPLICATIONS

Dental schools must identify challenges to patient safety at their teaching clinics and introduce risk reduction strategies to protect their patients and foster a safety culture in dental education.

Development of a trigger tool to identify adverse events and no-harm incidents that affect patients admitted to home healthcare

BACKGROUND

Adverse events (AEs) and no-harm incidents are common and of great concern in healthcare. A common method for identification of AEs is retrospective record review (RRR) using predefined triggers. This method has been used frequently in inpatient care, but AEs in home healthcare have not been explored to the same extent. The aim of this study was to develop a trigger tool (TT) for the identification of both AEs and no-harm incidents affecting adult patients admitted to home healthcare in Sweden, and to describe the methodology used for this development.

METHODS

The TT was developed and validated in a stepwise manner, in collaboration with experts with different skills, using (1) literature review and interviews, (2) a five-round modified Delphi process, and (3) two-stage RRRs. Ten trained teams from different sites in Sweden reviewed 600 randomly selected records.

RESULTS

In all, triggers were found 4031 times in 518 (86.3%) records, with a mean of 6.7 (median 4, range 1-54) triggers per record with triggers. The positive predictive values (PPVs) for AEs and no-harm incidents were 25.4% and 16.3%, respectively, resulting in a PPV of 41.7% (range 0.0%-96.1% per trigger) for the total TT when using 38 triggers. The most common triggers were unplanned contact with physician and/or registered nurse, moderate/severe pain, moderate/severe worry, anxiety, suffering, existential pain and/or psychological pain. AEs were identified in 37.7% of the patients and no-harm incidents in 29.5%.

CONCLUSION

This study shows that adapted triggers with definitions and decision support, developed to identify AEs and no-harm incidents that affect patients admitted to home healthcare, may be a valid method for safety and quality improvement work in home healthcare.

Dental Providers' Perspectives on Diagnosis-Driven Dentistry: Strategies to Enhance Adoption of Dental Diagnostic Terminology

The routine use of standardized diagnostic terminologies (DxTMs) in dentistry has long been the subject of academic debate. This paper discusses the strategies suggested by a group of dental stakeholders to enhance the uptake of DxTMs. Through unstructured interviewing at the 'Toward a Diagnosis-Driven Profession' National Conference held on 19 March 2016 in Los Angeles, CA, USA participants were asked how enthusiastic they were about implementing and consistently using DxTMs at their work. They also brainstormed on strategies to improve the widespread use of DxTMs. Their responses are summarized by recursive abstraction and presented in themes. Conference participants were very enthusiastic about using a DxTM in their place of work. Participants enumerated several strategies to make DxTMs more appealing including: the use of mandates, a value proposition for providers, communication and education, and integration with EHRs and existing systems. All groups across the dental healthcare delivery spectrum will need to work together for the success of the widespread and consistent use of DxTMs. Understanding the provider perspective is however the most critical step in achieving this goal, as they are the group who will ultimately be saddled with the critical task of ensuring DxTM use at the point of care.

Quality Improvement and Reporting Systems: What the Oral and Maxillofacial Surgeon Should Know

Health care is an inherently dangerous environment, and patient safety should be an explicit goal of oral and maxillofacial surgery. Important components of a safety program include a nonpunitive safety culture, the implementation of patient safety practices, standardized incident reporting and adverse event analysis, regular self-assessment, and internal and external benchmarking. Implementation of a safety program requires the strong commitment of leadership and the engagement and empowerment of all employees. Oral and maxillofacial surgery can become the model dental specialty by implementing patient safety programs for office-based surgery. The programs could then be used by all dental practitioners performing oral surgery in the office.

Operator-related aspects in endodontic malpractice claims in Finland

OBJECTIVE

We analyzed operator-related differences in endodontic malpractice claims in Finland.

MATERIALS AND METHODS

Data comprised the endodontic malpractice claims handled at the Patient Insurance Centre (PIC) in 2002-2006 and 2011-2013. Two dental advisors at the PIC scrutinized the original documents of the cases (n = 1271). The case-related information included patient's age and gender, type of tooth, presence of radiographs, and methods of instrumentation and apex location. As injuries, we recorded broken instrument, perforation, injuries due to root canal irrigants/medicaments, and miscellaneous injuries. We categorized the injuries according to the PIC decisions as avoidable, unavoidable, or no injury. Operator-related information included dentist's age, gender, specialization, and service sector. We assessed level of patient documentation as adequate, moderate, or poor. Chi-squared tests, t-tests, and logistic regression modelling served in statistical analyses.

RESULTS

Patients' mean age was 44.7 (range 8-85) years, and 71% were women. The private sector constituted 54% of claim cases. Younger patients, female dentists, and general practitioners predominated in the public sector. We found no sector differences in patients' gender, dentists' age, or type of injured tooth. PIC advisors confirmed no injury in 24% of claim cases; the advisors considered 65% of injury cases (n = 970) as avoidable and 35% as unavoidable. We found no operator-related differences in these figures. Working methods differed by operator's age and gender. Adequate patient documentation predominated in the public sector and among female, younger, or specialized dentists.

CONCLUSIONS

Operator-related factors had no impact on endodontic malpractice claims.

Performance of trigger tools in identifying adverse drug events in emergency department patients: a validation study

AIMS

Trigger tools are retrospective surveillance methods that can be used to identify adverse drug events (ADEs), unintended and harmful effects of medications, in medical records. Trigger tools are used in quality improvement, public health surveillance and research activities. The objective of the study was to evaluate the performance of trigger tools in identifying ADEs.

METHODS

This study was a sub-study of a prospective cohort study which enrolled adults presenting to one tertiary care emergency department. Clinical pharmacists evaluated patients for ADEs at the point-of-care. Twelve months after the prospective study's completion, the patients' medical records were reviewed using eight different trigger tools. ADEs identified using each trigger tool were compared with events identified at the point-of-care. The primary outcome was the sensitivity of each trigger tool for ADEs.

RESULTS

Among 1151 patients, 152 (13.2%, 95% confidence intervals (CI) 11.4, 15.3%) were diagnosed with one or more ADEs at the point-of-care. The sensitivity of the trigger tools for detecting ADEs ranged from 2.6% (95% CI 0.7, 6.6%) to 15.8% (95% CI 10.6, 22.8%). Their specificity varied from 99.3% (95% CI 98.6, 99.7) to 100% (95% CI 99.6, 100%).

CONCLUSION

The trigger tools examined had poor sensitivity for identifying ADEs in emergency department patients, when applied manually and in retrospect. Reliance on these methods to detect ADEs for quality improvement, surveillance, and research activities is likely to underestimate their occurrence, and may lead to biased estimates.

How dental team members describe adverse events

BACKGROUND

Although some patients experience adverse events (AEs) resulting in harm caused by treatments in dentistry, few published reports have detailed how dental providers describe these events. Understanding how dental treatment professionals view AEs is essential to building a safer environment in dental practice.

METHODS

The authors interviewed dental professionals and domain experts through focus groups and in-depth interviews and asked them to identify the types of AEs that may occur in dental settings.

RESULTS

The initial interview and focus group findings yielded 1,514 items that included both causes and AEs. In total, 632 causes were coded into 1 of the 8 categories of the Eindhoven classification, and 882 AEs were coded into 12 categories of a newly developed dental AE classification. Interrater 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 and 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.

Systematic review of patient safety interventions in dentistry

Background

The concept of patient safety in dentistry is in its infancy, with little knowledge about the effectiveness of tools or interventions developed to improve patient safety or to minimise the occurrence of adverse events.

Methods

The aim of this qualitative systematic review was to search the academic and grey literature to identify and assess tools or interventions used in dental care settings to maintain or improve patient safety. All study designs were included from all dental care settings. Outcome measures were: patient safety, harm prevention, risk minimization, patient satisfaction and patient acceptability, professional acceptability, efficacy, cost-effectiveness and efficiency. Quality assessments were performed on the included studies based on CASP tools. Further analysis was undertaken to discover whether any of the tools had been trialled or verified by the authors, or by subsequent authors.

Results

Following abstract screening, and initial qualitative synthesis, nine studies were found to meet the inclusion criteria with 31 being excluded following initial analysis. Tools identified included: checklists (4 studies), reporting systems (3), the use of electronic notes (1) and trigger tools (1). Grey literature searching did not identify any further appropriate studies. In terms of study design, there were observational studies including audit cycles (5 studies), epidemiological studies (3) and prospective cluster randomised clinical trials (1). The quality of the studies varied and none of their outcomes were verified by other researchers. The tools identified have the potential to be used for measuring and improving patient safety in dentistry, with two surgical safety checklists demonstrating a reduction in erroneous dental extractions to nil following their introduction. Reporting systems provide epidemiological data, however, it is not known whether they lead to any improvement in patient safety. The one study on trigger tools demonstrates a 50 % positive predictive value for safety incidents. It is not clear as to what impact the introduction of electronic guidelines has on patient safety outcomes.

Conclusions

This systematic review finds that the only interventions in dentistry that reduce or minimise adverse events are surgical safety checklists. We believe this to be the first systematic review in this field; it demonstrates the need for further research into patient safety in dentistry across several domains: epidemiological, conceptual understanding and patient and practitioner involvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-015-0136-1) contains supplementary material, which is available to authorized users.

Lessons learned from dental patient safety case reports

BACKGROUND

Errors are commonplace in health care, including dentistry. It is imperative for dental professionals to intercept errors before they lead to an adverse event and to 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 framework, as well as at the practice level, in which crew resource management is a tested paradigm. Supporting patient safety at both the profession and dental practice levels relies on understanding the types and causes of errors, which have not been well studied.

METHODS

The authors performed a retrospective review of dental adverse events reported in the literature. 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

The authors identified 182 publications (containing 270 cases) through their search. Delayed treatment, unnecessary treatment, or disease progression after misdiagnosis was the largest type of harm reported. Of the reviewed cases, 24.4% of those patients involved in an adverse event experienced permanent harm. One of every 10 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; however, the overall dearth of publications on adverse events in the dental literature points to the need for more study.

PRACTICAL IMPLICATIONS

Siloed and incomplete contributions to dentistry's understanding of adverse events in the dental office are threats to dental patients' safety. Publishing more, and more comprehensive, case reports on adverse events is recommended for dental practitioners.

The dangers of dental devices as reported in the Food and Drug Administration Manufacturer and User Facility Device Experience Database

BACKGROUND

The authors conducted a study to determine the frequency and type of adverse events (AEs) associated with dental devices reported to the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

The authors downloaded and reviewed the dental device-related AEs reported to MAUDE from January 1, 1996, through December 31,2011.

RESULTS

MAUDE received a total of 1,978,056 reports between January 1, 1996, and December 31, 2011. Among these reports, 28,046 (1.4%) AE reports were associated with dental devices. Within the dental AE reports that had event type information, 17,261 reported injuries, 7,777 reported device malfunctions, and 66 reported deaths. Among the 66 entries classified as death reports, 52 reported a death in the description; the remaining were either misclassified or lacked sufficient information in the report to determine whether a death had occurred. Of the dental device-associated AEs, 53.5% pertained to endosseous implants.

CONCLUSIONS

A plethora of devices are used in dental care. To achieve Element 1 of Agency for Healthcare Research and Quality's Patient Safety Initiative, clinicians and researchers must be able to monitor the safety of dental devices. Although MAUDE was identified by the authors as essentially the sole source of this valuable information on adverse events, their investigations led them to conclude that MAUDE had substantial limitations that prevent it from being the broad-based patient safety sentinel the profession requires.

PRACTICAL IMPLICATIONS

As potential contributors to MAUDE, dental care teams play a key role in improving the profession's access to information about the safety of dental devices.