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Med Oral Patol Oral Cir Bucal. 2011 Sep 1;16 (6):e805-9. Patient safety in dentistry

Journal section: Oral Surgery doi:10.4317/medoral.17085

Publication Types: Research http://dx.doi.org/doi:10.4317/medoral.17085

Patient safety in dentistry: Dental care risk management plan

Bernardo Perea-Pérez 1 Andrés Santiago-Sáez 2, Fernando García-Marín 3, Elena Labajo-González 4, Alfonso

Villa-Vigil 5

1
Director of the Spanish Observatory of Safety for Dentistry Patients (OESPO). Professor of the School of Legal and Forensic
Medicine of Madrid. School of Medicine. Universidad Complutense de Madrid
2
Member of the Spanish Observatory of Safety for Dentistry Patients (OESPO). Professor of the School of Legal and Forensic
Medicine of Madrid. School of Medicine. Universidad Complutense de Madrid
3
Member of the Spanish Observatory of Safety for Dentistry Patients (OESPO). Member of the Board of Directors of the Spanish
Society for Oral and Maxillofacial Surgery (SECOM)
4
Member of the Spanish Observatory of Safety for Dentistry Patients (OESPO). Professor of the School of Legal and Forensic
Medicine of Madrid. School of Medicine. Universidad Complutense de Madrid
5
President of the General Board of Dentists of Spain

Correspondence:
Escuela Medicina Legal y Forense de Madrid,
Facultad de Medicina. Pabellón 7,
Avda. Complutense s/n, Perea-Pérez B, Santiago-Sáez A, García-Marín F, Labajo-González E,
28040. Madrid, Spain. Villa-Vigil A. Patient safety in dentistry: Dental care risk management
[email protected] plan. Med Oral Patol Oral Cir Bucal. 2011 Sep 1;16 (6):e805-9.
http://www.medicinaoral.com/medoralfree01/v16i6/medoralv16i6p805.pdf

Article Number: 17085 http://www.medicinaoral.com/

© Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
Received: 04/05/2010 eMail: [email protected]
Accepted: 06/09/2010 Indexed in:
Science Citation Index Expanded
Journal Citation Reports
Index Medicus, MEDLINE, PubMed
Scopus, Embase and Emcare
Indice Médico Español

Abstract
Objectives: Although the safety of patients has been one of the inherent concerns of dental practice, but because
the proposals made in the field of dentistry are few and improperly structured, this paper constitutes an attempt
to present a proposal titled “Plan for Dental Health Care Risk Management,” promoted by the General Council of
Dentists of Spain, including a description of the proposed work methodology.
Design: The “risk management plan” proposed in this paper is based on applying the basic concepts dealt with in
patient safety to the field of dentistry, due to the fact that the available bibliography contains no specific “health
care risk management plan” for dentistry specifically.
Results and conclusions: In order to implement health care risk management in the field of dental care provided at
any level throughout Spain, a seven-step plan which covers the main objectives in Patient Safety is provided.

Key words: Adverse events, error, clinical risk management, patient safety, oral surgery.

Introduction of Health Care in America of the Institute of Medicine,

Patient safety has become one of the focal points of achieving safe health care practices became a top priori-
health care in recent years. Though the concern for not ty for health care authorities. At present, there are many
harming patients (the Hippocratic “primum non noce- institutions which have developed programs and initia-
re”) has been a fundamental factor in health care since tives to improve patient safety (1-3). One representative
it first began, as of the publication in 1999 of the study example would be the “World Alliance for the Safety of
titled “To err is human” by the Committee on Quality Patients” promoted by the World Health Organization

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(WHO) (4) or the Luxembourg Declaration of the Eu- - Definitions.

ropean Union (5). The following definitions are provided by the ICPS
Within the field of dentistry, the proposals have not (International Patient Safety Classification) proposed
been as numerous or as structured. Although patient by the World Alliance for Patient Safety of the World
safety has also been one of the inherent concerns in Health Organization (WHO) (11).
dental practice, and alerts and recommendations have 1. Patient Safety.
been given out on pharmaceutical products, dental ma- Patient safety means a decrease in (or elimination of, to
terials and clinical procedures, the programs organized the greatest extent possible) the harm to patients caused
specifically for promoting patient safety have been few by treatments provided, or from accidents associated
(6-10). At the same time, there is little structured or well- with those treatments.
studied data regarding adverse events in dentistry. The 2. Risk Management.
existing bibliography describes isolated clinical cases This is the attempt to identify, evaluate and deal with
or short series on the basis of which empirical clinical problems which may cause harm to patients, to file
recommendations are made. complaints about malpractice and to avoid unnecessary
There are reasons which explain this delay in dentistry economic losses for health care providers.
when compared with most other health care professions: 3. Adverse Event.
- The harm produced is generally less severe. Unexpected result of a health care treatment which
- The patients are ambulatory (this makes it difficult to be- leads to prolonging treatment, some type of morbidity,
come aware of and follow up on many adverse events). mortality or simply any harm which the patient should
- There is a great dispersion of dental care which makes not have suffered (12).
it difficult to collect data. It is a broad concept which includes errors, accidents,
- Dental care is fundamentally private, and the fear may delays in providing care, negligence, etc., but not the
exist that reporting adverse events might have some re- complications inherent to the patient’s disorder or di-
percussion on the commercial profits of clinics. sease itself.
- There is not a generalized culture which deals with 4. Error.
patient safety. The motivations are different for profes- Mistake due to action or omission in health care prac-
sionals, and the potential for undertaking educational tice, whether an error of planning or an error of execu-
campaigns that reach all dentists is limited due to their tion (13). The error may or may not lead to the existence
widespread dispersion. of an adverse event.
Nevertheless, there are many reasons why we believe 5. Near miss.
that dentistry must become more active in dealing with Event which nearly causes harm to the patient and which
everything involved in patient safety. Among these rea- is avoided by luck or due to action at the last moment
sons is the fact that we handle potentially dangerous (14). One example would be prescribing an antibiotic
pharmaceuticals (by themselves or as a result of their derived from penicillin to an allergic patient, because
interactions), dental procedures are becoming more this information does not appear in his or her clinical re-
aggressive (especially the surgical techniques related cord, and gaining knowledge of that allergy because the
with implantology), we deal with technical instruments patient informs us of it when we provide him or her with
(ionizing radiation, lasers, etc.) which may be harmful, the prescription. Various studies have found that many
and the contact of our instruments with the blood and more such incidents (near miss) occur than do actual ad-
bodily fluids of patients may constitute potential sour- verse events. In the specific case of prescribing pharma-
ces for the transmission of diseases. ceuticals, it is estimated that approximately seven times
Due to all of the above, we believe that dental practice more near misses occur than adverse events (15).
must more actively become involved in the international 6. Accident.
trend towards patient safety. It is with this goal in mind that Random, unforeseen and unexpected event which
the General Council of Dentists of Spain has promoted the causes harm to the patient or any other type of harm
“Plan for Prevention of Health Care Risks in Dentistry.” (material damage, harm to health care personnel, etc.).
The objective of this article is to explain the goals of this 7. Negligence.
plan, as well as its organization and work methodology. Error which is difficult to justify due to a lack of knowl-
edge or basic skills, failure to take minimum precau-
Materials and Methods tions, carelessness, etc. (16).
No available bibliography exists regarding any “plan for - Professional error in dentistry.
health care risk management” specific to dentistry. Be- The literature on error in medicine is extensive, espe-
cause of this, the “risk management plan” proposed in cially in terms of adverse drug events, errors in pres-
this paper is based on applying the basic concepts dealt cription and medication errors, and errors in Intensive
with in patient safety to the field of dentistry. Care Units, trauma care or anesthesia (17-19). However,

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there are hardly any studies dealing with the frequency In order to be able to achieve the Plan’s general objec-
and effects of the errors committed in dental practices. tive, the following specific goals have been established:
This may be due to the limited repercussion on patient 1. To promote a Culture of Patient Safety in dental
health which they tend to have, as well as the great dis- care.
persion of clinical records, which makes any investiga- The culture of safety was defined by the ACSNI (Advi-
tion quite difficult. sory Committee on the Safety of Nuclear Installations):
The errors in dental care may be of a human origin (in “An organization’s culture of safety is the product of in-
which a professional reaches an erroneous decision or dividual and group values, attitudes, perceptions, skills
provides a deficient treatment), but in most cases their and patterns of behavior which lead to commitment,
occurrence is to a great degree dependent upon many style and ability in the management of the health and
contributing factors related with the system, which lead safety of an organization. Those organizations with a
to a chain of errors and end up causing harm to the pa- positive safety culture are characterized by communi-
tient (20). cation based on mutual trust, by shared perceptions of
- Oral surgery and patient safety. the importance of safety and by trust in the effective-
Within the realm of health care, all of the research points ness of measures for prevention.”
out as the causes of the largest number of adverse events 2. We believe that there is a significant deficiency in
the prescription and administration of drugs, as well as terms of patient safety within the realm of health care
surgical activity (21,22). Since the advent of surgery, the- in general, and dental care in particular. Because of
re has been an awareness of the potential damage which this, we believe it is absolutely fundamental to promote
surgery may cause. The data on surgical complications this culture of patient safety among practicing dentists,
occurring in industrialized nations shows that the pe- patients and (public or private) dental care managers.
rioperatory death rate lies between 0.4-0.8%, while the To achieve this, we propose the promotion of increased
rate of major complications is from 3-17% (21,22). In awareness amongst dentists about the general aspects
industrialized nations, nearly half of all adverse events and basic measures involved in patient safety, as well as
are related with surgical care. Of these cases, at least the main research works about this topic.
half are avoidable (21,22). In light of these data, in 2007 3. Creating an organizational structure for the manage-
the “World Alliance for Patient Safety” (dependent upon ment of dental care risks.
the World Health Organization) established the “Global The manner of administrative organization in Spain,
Patient Safety Challenge: Safe Surgery Saves Lives” as which has an independent health care system in each of
its second main objective. This change revolves around its 17 autonomous regions, conditions the structure of
four large areas: preventing infection of the surgical the Observatory at two levels:
wound, safe anesthesia, safe surgical equipment and a. State-wide level: Spanish Observatory for Dental Pa-
the measurement of surgical services. As a part of this tient Safety (OESPO).
initiative, the “World Alliance for Patient Safety” laun- b. Autonomous regional level: Functional units for den-
ched the “Surgical Safety Checklist” in June 2008. This tal patient safety dependent upon each Autonomous Re-
Checklist was proposed as a simple and easy-to-use tool gional Health Department. Each of these units would
which ensures compliance with the key patient safety possess one representative in the OESPO, who would be
key safety elements. the intermediary with the health care authorities of their
Amongst the specific characteristics of oral surgery autonomous region.
which we could point out are its less invasive nature 4. Developing tools for the identification, analysis and
than other surgical specialties, the widespread use of assessment of risks related with dental care.
local or loco-regional anesthesia, its generally ambula- This specific objective can, in turn, be divided into a
tory nature and the great geographic dispersion of oral further three:
health care centers. Therefore, one of the first tasks to a. Implementing a system for notification and recording
carry out in the field of safety for patients who undergo of adverse events which take place in professional prac-
oral surgery procedures should be the adaptation of ge- tice. Gaining knowledge of risk situations is basic to the
neral surgical checklists designed for major surgery in implementation of any risk management system. To do
hospitals to this specific field of care. so, it is necessary to have reliable notification system for
any type of adverse event, which ensures the anonymity
Results of the person who reports it. This topic seems to be of
Objectives of the “Plan for Health Care Risk Prevention such importance to us that it will be developed as a se-
in Dentistry.” parate specific objective.
The general objective is to implement the management b. Classifying the types of adverse events on the basis
of health risks in the dental care provided at any level of of a specific taxonomy. It is not useful to possess a lar-
care within Spanish territory. ge amount of data without first having a taxonomy that

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allows us to classify and quantify the adverse events be- I. Prevention of infections at dental offices.
fore studying them in detail. At present, any classifica- II. Prevention of surgical error.
tion should be based on the ICPS (International Patient III. Prevention of error in prescribing drugs, etc.
Safety Organization) (11) or on the taxonomy proposed In turn, the measures may be translated into simple re-
by the Joint Commission (23). commendations or recommendations of good clinical
c. Using tools for the study of reported adverse events practices. This is why it is important to analyze the ex-
(root cause analysis -CRA-) and prevention of other periences and recommendations of other similar enti-
possible adverse events (failure mode and effects analy- ties.
sis -FMEA-). It makes no sense to have information on 7. Ongoing training of professionals on Patient Safety.
adverse events if that information is not properly analy- This is a specific objective closely related with Objecti-
zed. In patient safety, basically two tools are used (with ve 1 (promote a culture of Patient Safety), but it is res-
all of their variants): prospective and respective tools. tricted to the arena of health care professions and the
The classical retrospective analysis tool is root cause care structures in which dentists perform their work.
analysis (RCA), which would be applicable to those ad- This ongoing training should include a system of im-
verse events of sufficient significance (24,25). There are mediate alerts in the event of potentially serious cases,
other similar procedures but which are simplified for and the existence of a monthly bulletin in an electronic
occurrences of lesser transcendence. format, containing the most important information.
The most widely used prospective analysis tool is fa- 8. Research in the field of Dental Patient Safety.
ilure mode and effects analysis (FMEA). This tool uses The final specific objective, once the others have been
reported data to prevent similar (potentially similar) achieved, is to increase knowledge about dental patient
events in similar procedures (26). safety. This research may be structured around research
5. Establishing lines of information on adverse events. projects, doctoral theses or any other applicable instru-
It is absolutely indispensable to possess truthful infor- ment of education or research.
mation on the occurrence of adverse events in order to
be able to determine any measures for prevention. The Discussion
differences existing between other health care and den- Patient safety constitutes a whole culture of which den-
tal care leads to the loss of most of this information. At tal practices cannot remain on the sidelines. Neverthe-
present only that which gives rise to legal conflicts can less, up to the present time, few steps have been taken
only be recovered, and even though only partially. to bring dentistry in line with the other health care pro-
Given this situation, it is reasonable to establish diffe- fessions in this respect.
rent levels within these lines or sources of information: Because there are no “dental risk management plans”
a. Bibliographic sources of information. similar to the one proposed, its proposal is not based on
b. Sources of information originating from organizations any other dentistry-related documents.
similar to the OESPO (whether medical or dental). Due to the breadth and complexity of the problem, we
c. Sources of information originating from ethical com- deemed it appropriate to design a plan which can be
plaints or court claims. carried out sequentially and which guarantees that the
d. Sources of information originating from voluntary objectives sought out are achieved.
anonymous reports made by professionals or patients The plan consists of seven steps which cover the main
(27). In this sense, the report by the Institute of Medi- objectives sought in Patient Safety. Working on patient
cine (IOM) established that notification systems consti- safety requires seeking humble objectives and, above
tute a key strategy for learning form mistakes and avoi- all, remaining perseverant in terms of the difficulties
ding their repetition. which will inevitably arise. Through this article, we
6. Establishing measures to prevent health care risks by would like to offer our cooperation and share knowled-
elimination or reduction. ge and work methodologies with any other dental orga-
These measures are to be established, on a specific ba- nization that works to improve patient safety.
sis, after identifying risks (general or specific to one
center). Their purpose is the prevention of the risks
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