Autumn In-Brief 2018 V10 FINAL - Flipbook - Page 5
Continued from previous page.
The following list outlines the recommended actions to
prevent wrong tooth extraction:
• Learning from previous events – including full
investigation and root cause analyses.
• Engaging the clinical team when developing Correct
Site Surgery Policies.
• Using the LocSSIPs template and guidelines from
NHS England/RCS England.
• Developing a Correct Site Surgery checklist that is
appropriate for the clinical environment.
• Providing training for staff on the use of the checklist.
• Ensuring that the checklist is being used correctly
through active audits of the processes involved.
• Supporting the clinical team throughout the process
and not taking punitive action when incidents do
occur.
Correct Site Surgery checklists must incorporate the
following stages:
Sign in:
The clinical team check that the correct patient is
present and that all of the necessary clinical
information and equipment is available and
functioning.
Time out:
At this point, the clinical team pause in order to run
through the checks to ensure that the correct
treatment is about to take place. The LocSSIPs group
decided that this should include a two person check
with the assisting clinician or nurse.
Sign out:
The correct procedure is verified and the clinical team
discuss any problems encountered and decide how to
learn from these for future procedures.
Through continued work and awareness of patient safety
issues, I hope that we can reduce the incidence of wrong
tooth extraction through instilling a patient safety culture
in dentistry. In my own NHS trust, I was impressed
recently when the dental nurse prompted me to use the
checklist, which I had developed – this is exactly the
culture that we have worked to achieve!
Edmund Bailey BDS (hons) MFDS RCS (Ed)
MPhil M Oral Surg RCS (Ed) is a Consultant
Oral Surgeon at Barts and The London
School of Medicine and Dentistry.
Edmund has undertaken extensive work
on improving patient safety in dentistry.
And what of root causes?
The term root cause has been referred to since as
early as 1905, where the root cause of a problem with
health care in the Rhondda Valley was reported in the
Lancet. Over the years since, the term has been used
in investigation methodology, where investigations
have been conducted using root cause analysis (RCA)
principles. Thinking has developed from simply
identifying the root cause as the most basic causal
factor to one that, if changed, would have altered the
outcome.
The purpose of carrying out RCA investigations is to
make improvements so that the chance of error is
reduced or removed. In order to do this one cannot
simply look for the most basic causal factor, but to in
fact look for the most basic causal factor which could
be corrected. As a result, root cause analysis
methodology now refers to the root cause being the
most basic/earliest causal factor which is amenable to
management intervention. A root cause is said to be
the deepest cause in a causal chain that can be
resolved. If the deepest cause in a causal chain cannot
be resolved, it's not a real problem.
In 2016 the American National Patient Safety Forum
recommended a new approach to root cause analysis
and in doing so renaming root cause analysis as RCA².
In the guidance they refocus to concentrate on
systems-level type causations and contributing factors
ensuring that the resulting corrective actions that
address these systems-level issues must not result in
individual blaming or punitive actions.
Further, they include an explanation of why “human
error” is not an acceptable Root Cause. It may be true
that a human error was involved in an adverse event,
the very occurrence of a human error implies that it can
happen again. Human error is inevitable. If one wellintentioned, well-trained healthcare worker working in
his or her typical environment makes an error, there
are system factors that facilitated the error. It is critical
that we gain an understanding of those system factors
so that we can find ways to remove or mitigate them.
When the involved member of staff is disciplined,
counselled, or re-trained, we may reduce the likelihood
that the event will recur with that person, but we don’t
address the probability that the event will occur with
other providers in similar circumstances. Wider training
is also not always an effective solution; there is
turnover to consider, and a high-profile event today
may be forgotten in the future. Solutions that address
human error directly (such as remediation, training, and
redrafting of policies) are all weaker solutions
compared to systemic solutions (such as process
changes) which are much stronger. This is why it is so
important to understand the system factors facilitating
human error and to develop a whole-system approach.
(By Chrissie Cooke, Niche Associate)
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