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Joint Commission considers ‘wrong site block dental local anesthesia’ a sentinel event

August 22, 2019

By Kimber Solana

The Joint Commission, the nation’s largest standards-setting and accrediting body in health care, clarified to the Association in July 11 that it continues to consider a “wrong site block dental local anesthesia” as a sentinel event — a term generally defined as an incident that results in death, permanent harm or severe temporary harm.
   
Dr. Dave Preble, ADA Practice Institute vice president, said the Joint Commission could not make an exception for dental block anesthesia without opening a Pandora’s Box, possibly leading to requests for exceptions for all manner of block anesthesia.

The clarification stems from a correspondence last year when the Association requested the Joint Commission reevaluate and consider that all wrong site local anesthesia administrations in dentistry were patient safety events but did not rise to a level of sentinel events.

The Joint Commission responded with a July 2018 letter that it considered “wrong site infiltration of local anesthesia” a patient safety event that did not rise to the category of a sentinel event.

The addition of the word “infiltration” in the Joint Commission’s letter led to some misunderstanding in the interpretation. The terms “block” and “infiltration” denote different specific injections — especially in dentistry.
   
“Local anesthesia needs to be delivered to both the maxilla and the mandible,” Dr. Preble said in an April 2019 letter to the Joint Commission. “The maxilla is composed of porous bone that lends itself to local anesthesia direct infiltration, allowing the local anesthetic agent to reach the tooth, nerve and surrounding structures.”

However, the mandible is composed of dense bone that “does not lend itself to effective local anesthetic direct infiltration, so local anesthetic blocks are commonly used,” he added.

“The addition of the word ‘infiltration’ has caused only infiltration types of wrong site local anesthetic injections to be considered patient safety events, but not sentinel events, and wrong site local anesthetic block injections to be considered sentinel events,” Dr. Preble wrote, requesting that the Joint Commission remove the word “infiltration” from its decision.

The Joint Commission declined, citing it could cause other health care providers to request exemptions for all manner of block anesthesia, Dr. Preble said.  

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.

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.