Autumn In-Brief 2018 V10 FINAL - Flipbook - Page 4
Pull the other one
Edmund Bailey is examining dental Never Events
Patient safety specific to dentistry is an area which has
seldom been discussed until recently. There is still a lack
of consensus as to what constitutes a Patient Safety
Incident (PSI) in dentistry. Of course, all practitioners are
professionals and they will do their utmost to protect their
patients from harm. However, the systems in dentistry
have yet to be fully explored in relation to patient safety.
Why is this the case? There are several reasons; when
compared to other surgical procedures, there are issues
with contra-laterality, non standardised charting systems,
impacted teeth and orthodontic treatment requiring
extraction of otherwise healthy teeth to create space. It is
not possible to site mark teeth in an accurate fashion.
life. There is of course potential for errors to occur with
such treatments. Wrong tooth extraction has been
designated as a Never Event by NHS England for several
years. Furthermore, wrong tooth extraction continues to
top the charts as being the most frequently occurring
surgical Never Event based on NHS England’s data.
Perhaps wrong tooth extraction is one of the worst things
that can happen in a dental chair.
Should wrong tooth extraction be designated as a ‘Never
Event’? This has been the subject of active debate in the
dental profession and especially within the oral surgery
community. In order to fit the definition of a Never Event,
the patient must have the potential to experience serious
harm or death, and for surgical Never Events, the
patient’s anatomy must be permanently altered.
Also, a patient may have up to 32 (or more in cases of
One might ask, what is the worst thing that can happen in supernumerary teeth) teeth in their head - this of course
poses an additional risk of wrong site surgery when
the dental chair? Death perhaps - but this occurring due
compared to a knee for example – most patients will have
to dental treatment is exceptionally rare, especially since
general anaesthesia was banned in dental practices in the only two knees!
1990s. Deaths in dental practice are mainly due to
Additionally, the vast majority of patients undergoing tooth
patients with pre-existing conditions who would have
extraction are conscious and (to varying extents) anxious;
suffered their fatal cardiac event whether they were in the this can increase the risk of wrong site surgery. Many of
dental practice, on the bus or at home.
the incidents relate to human error, but there is a lack of
understanding of how systems errors apply to dentistry.
Tooth extraction can be a significant event in a person’s
The latest full year figures show that during 2017/18
wrong tooth extraction was reported on 32 occasions by
NHS trusts in England, this was the most frequent
surgical Never Event for that year. During 2016/17, the
figure was 42! Provisional figures covering the period
from 1 April to 31 July 2018 report 19 incidents extrapolation of this data would mean that 57 such
incidents might be expected during the current financial
year. We must also note that this figure will not include
the majority of wrong tooth extractions that occur in
primary care dentistry (where the majority of dental care
is delivered) as there is no way of reporting these
incidents at the present time.
The impact to the patient of wrong tooth extraction would
not be considered to be as devastating as removal of the
wrong kidney, for example. The consequences of the
wrong kidney would be far reaching and potentially fatal;
the wrong tooth, however, could be replaced using
modern prosthetic dentistry such as dental implants.
Patient views on this matter are not widely reported;
however, a recent Ipsos MORI survey commissioned by
the General Dental Council found that of 1,232
respondents, 13% felt that a dentist should be struck
off if they accidentally extract the wrong tooth, and
36% felt that they should be suspended from the
register. So much for the ‘no blame culture’ in healthcare!
Prevention is better than cure, so what steps can be taken
to prevent wrong tooth extraction? Since NHS England
classified ‘wrong tooth extraction’ as a Never Event in
2015 there have been several pieces of work completed,
working on prevention of wrong tooth extraction. The
main output is the LocSSIPs (Local Safety Standards for
Invasive Procedures) pathway for Dental Extractions
developed by RCS England with multiple stakeholders
from dentistry and wider healthcare - this launched in
2017.
4