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Not 'sentinel events': Joint Commission, ADA agree on two dentistry-related patient safety occurrences label

Federal Dental Services, Veterans Affairs worked with Association in resolving issue

August 28, 2018

By Kimber Solana

The Joint Commission, the nation's largest standards-setting and accrediting body in health care, agreed with the ADA that two dentistry-related patient safety occurrences should not be labeled as sentinel events. A sentinel event is generally defined as an incident that results in death, permanent harm or severe temporary harm.

In a July 31 letter to the Association, Edward Pollak, M.D., Joint Commission patient safety officer and medical director, stated that the following dental-specific situations are not sentinel events:

  • Wrong site infiltration of local anesthesia.
  • Swallowed small instruments during dental procedures, specifically when the swallowed item passes through without incident.
Photo of Dr. Crowley
Dr. Crowley

The correspondence was in response to a July 18 letter from ADA President Joseph P. Crowley highlighting that the ADA felt the Joint Commission should reevaluate the two occurrences to be patient safety events in a lesser category than sentinel events. The Federal Dental Services and the U.S. Department of Veterans Affairs had brought the category issue to the attention of the Association. Sentinel events are one category of patient safety events that require a higher level of reporting and scrutiny, to assist accredited programs in identifying process issues and improvements that can reduce the likelihood of these events occurring in the future.

Other patient safety events are incidents or conditions that could have resulted or did result in harm to a patient. They can be, but are not necessarily, the result of a defective system or process design, a system breakdown, equipment failure or human error. These events also include instances that could have but do not cause harm to a patient, as well as close calls.

"It has come to our attention that [The Joint Commission] has determined that certain patient safety events in the delivery of dental care that are not sentinel events, have been determined to be sentinel events," Dr. Crowley said in the letter to Mark R. Chassin, M.D., president and CEO of the Joint Commission.

The ADA's letter underscored that wrong site local anesthesia was considered a sentinel event because it is considered an invasive procedure — by virtue of the introduction of a needle into a body or by the introduction of a pharmacologic agent through the needle, regardless of the severity of the harm to a patient.

However, the ADA stated, "then every vaccine inoculation and every intramuscular or intravenous injection would be an invasive procedure."

The ADA's position, Dr. Crowley said in the letter, is that wrong site local anesthesia is not an invasive procedure unless all other needle stick pharmacologic introductions are treated likewise.

"Furthermore, if all such procedures are invasive, then there must be a reconsideration of the rule that the severity of the harm matters not for wrong site administration," the letter stated. "For sentinel event to remain meaningful and effective, severity of harm can never be disregarded as a determinant, since severity of harm is the single most important distinguishing factor between sentinel events and other patient safety events."

In the issue of swallowed small instruments, such as endodontic files or burs, the ADA said this patient safety event often does not rise to the level of sentinel events.

Normal protocol for a swallowed instrument is to have the patient radiographically examined to ensure that the instrument was indeed swallowed and not aspirated into the lungs, Dr. Crowley said.

"If the instrument was aspirated, there is no question that it would be a sentinel event," he added. "However, if the instrument has been swallowed, the probability that the instrument will pass, without adverse effect, through the gastrointestinal tract is very high." No intervention would be needed in such cases.

In the Joint Commission's response to the ADA's requests, Dr. Pollak said the commission concurred.

"We accept your view and agree that wrong site local anesthesia injection is not a sentinel event," the letter from The Joint Commission said. "We also concur with your assertion that these should be looked at as patient safety events by the appropriate local quality and safety teams."

In regard to the swallowing of small instruments, the Joint Commission said that aspiration and those that require further medical treatment to retrieve the swallowed instrument should be labeled as sentinel event. However, when it comes to swallowed foreign objects that routinely pass without incident, the Joint Commission agreed that these incidents are not sentinel events.

These issues have been particularly problematic for the Federal Dental Services and the ADA is pleased to have been able to succeed in assisting them through a very positive interaction with The Joint Commission, Dr. Crowley said.

"This collaboration between the Federal Dental Services and the ADA will hopefully continue to address important issues affecting member dentists," he said.