The Big PictureReporting adverse events
Section snippets
Background
The National Health Service (NHS) in England established safety databases 10 years ago to document patient safety incidents (PSIs). These occurrences can have severe consequences for patients and are distressing to health care professionals. The goal is to learn how to improve patient safety from reviewing past events. “Never” events have recently been defined relevant to dentistry as comprising wrong site block, wrong tooth extraction (permanent dentition only), wrong implant and/or incorrect
Methods
The NRLS data for January 2005 to May 2014 and the STEIS data for 2012-2013 and 2013-2014 were used to construct a list of free text elements. These elements were then analyzed thematically and reclassified based on the type of PSI reported.
Results
Between January 1, 2005 and May 30, 2014 a total of 32,263 PSIs were reported. In 47% of these, the patient suffered no harm, in 20% low harm, in 7% moderate harm, and in less than 1% severe harm. Death occurred in 23 incidents (Table 2).
Most (60%) of the serious harm and deaths occurred in acute trust wards and were related to oral and maxillofacial surgery (OMFS) (Fig 1). Twenty percent of these cases occurred in primary care. The location of care for most patients with serious harm or death
Preventive Strategies
Never events can nearly always be avoided if best practices are implemented. WSS, for example, can be prevented by reducing variation in procedures, promoting the development of safe behaviors, and supporting the exercise of responsibility. Never events are nearly always the result of multiple sources of error, which indicates that the system itself needs to be standardized and guidelines implemented universally. The NHS surgical safety taskforce proposed a strategy that has three equally
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Renton T, Sabbah W: Review of never and serious events related to dentistry 2005-2014. Br Dent J 221:71-79, 2016
Reprints available from W Sabbah, Dept of Dental Public Health, Kings College London; e-mail: [email protected]