Preventing Never Events in UK Dental Hospitals

December 15, 2016, Total Health Mag

In June of this year, 16 clinical directors of hospitals located throughout England and Ireland were solicited for response to a survey focused on one key safety initiative – the safer surgery checklist. Although three hospitals declined to respond, the 13 (10 in England and 3 in Ireland) that did provide detailed answers to the survey questions reported that they were not only utilising checklists with patients prior to performing common dental procedures, like tooth extractions, but they also felt strongly that a wrong tooth extraction fell under the category of reportable Never Events by NHS standards. This survey data highlights the commitment of most providers in providing the utmost quality care to patients and working to reduce the number of preventable incidents that could harm the patient for life.

Recent Changes to Standards

Nearly a decade ago, research pointing to the need for greater safety initiatives through UK’s healthcare system was published, focused on the consistent use of a safety checklist for surgical procedures occurring in hospital theatres or procedure rooms. The purpose of the checklist, designed after the airline industry’s in-flight safety checklist, was to reduce the number of serious, largely preventable incidents involving patient safety that would not occur if preventative measures were taken. These incidents, identified by the National Patient Safety Agency (NPSA) as Never Events, require prompt reporting on a local and national level to encourage prevention as well as accountability for providers involved. To help prevent Never Events from the start, all NHS organisations quickly adopted the checklist practice as a standard for patient safety.

However, Never Events were originally defined in somewhat ambiguous terms, leaving some medical providers in limbo as to what qualified as a surgical procedure and, more specifically, if tooth extractions fell into that category. In recent years, clarity has been provided to include wrong tooth extractions as a reportable Never Event. According to a representative from a leading medical solicitor firm in the UK, the NHS framework specifically includes wrong tooth extraction by expanding the definition to include surgical intervention performed on the wrong patient or the wrong site, like a wrong tooth.

With the recent update to the Never Event definition, it is promising to see that the recent survey results from dental hospitals around England and Ireland are implementing safety checklists for tooth extraction procedures to reduce the occurrence of harmful surgical missteps that could lead to a poor outcome for patients. In addition, nearly all hospitals that responded to the survey that wrong tooth extractions should follow standards for reporting Never Events.

Additional Tools for Preventing Wrong Site Incidents

While safer surgical checklists and the reporting of Never Events like wrong site surgery are both a step in the right direction toward preventing harmful outcomes that have a detrimental effect on a patient’s quality of life, more can be done to improve healthcare throughout the country. One of the most prominent reasons behind medical missteps is a lack of communication between the patient and his provider. In addition, lackluster training on certain procedures, understaffing, and a hospital culture focused on anything but patient safety play a significant role in how well – or how poorly – patient care is provided in the hospital setting.

Instead of relying solely on safer surgical checklists to improve the quality of care provided to patients, providers and the institutions for which they work must embrace the initiatives aimed at protecting individuals from Never Events and other poor care outcomes. Establishing safe spaces for doctors and staff to openly talk about healthcare innovation ideas, best practices, and difficult cases may provide an improvement to hospital culture that truly safeguards the patient’s experience. Similarly, advanced training on Never Events, the use of safer surgical checklists, and communication with staff and patients is a necessary link in the chain of greater quality healthcare throughout the country.

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