ADA council tasked with fostering prioritization of safety in dentistry
December 03, 2019
— Dr. Jessica Meeske, a pediatric dentist in Nebraska, believes that the dental community may have fallen behind the medical community in addressing the issue of safety for providers, their dental staff and, importantly, patients.
The private-practice owner has said she has first-hand experience seeing the gap, for one day a week she treats and operates on patients at her local hospital. She is also married to a physician.
Dr. Meeske has seen physicians use evidence-based, safety-related checklists, protocols and reporting systems that she said aren’t readily available or routinely used by dentists.
It’s not as if she is practicing unsafe dentistry, but it’s a subject not many dentists seem to be talking about.
It concerns her.
Dr. Meeske, as vice chair of the ADA Council on Advocacy for Access and Prevention, will have a hand in helping member dentists enhance the culture of safety in a new initiative that will bring the issue into the limelight.
The movement stems from the passage of Resolution 78H-2019, approved by the House of Delegates in September in San Francisco. It calls for a three-year framework for action for CAAP that wants to move forward in a “measured and methodical” manner on these efforts:
• The development of a curriculum in patient safety and encourage its adoption into training.
• The dissemination of information on patient safety through a variety of in-person, print, web and social media information vehicles on a regular basis.
• The inclusion of patient safety considerations in practice guidelines and in standards.
• The development of community-based initiatives for error reporting and analysis.
• The collaboration with other dental and health care professional associations and disciplines in a national summit on dentistry’s role in patient safety.
The resolution also called that an annual report be submitted to the House of Delegates detailing progress “nurturing this culture of safety in order to raise awareness, while alleviating fear and anxiety associated with making the dental environment safe for patients, providers and the dental team.”
Symposium raises awareness
A national symposium was convened, with the American Academy of Pediatric Dentistry’s Safety Symposium: Hidden Threats and Safe Practices: Steps to Creating a Safe Dental Home
that took place Nov. 8-9 in Chicago. The symposium was what organizers called a first-of-its-kind national look at safety in pediatric dental care, which served to provide practical tools and pertinent clinical advice on how to improve safety for patients, team members and pediatric dentists. The symposium featured experts from major areas of dental and medical practice that aimed to mitigate potential harm related to providing care. A highlight was a former astronaut who detailed the repeated and unreported safety lapses that doomed the 1986 Space Shuttle Challenger, which truly could have been avoided.
One of the organizers of the symposium was Dr. Paul Casamassimo, CAAP member, chief policy officer of the American Academy of Pediatric Dentistry and a past AAPD president. He is also a past president of the Ohio Dental Association and is on the medical staff at Nationwide Children’s Hospital in Columbus, Ohio.
Dr. Casamassimo said the symposium was meant to serve as a wake-up call for the profession. The landmark Institute of Medicine report “To Err is Human: Building a Safer Health System” was an eye-opening look at safety in the medical field when it was published two decades ago, but nothing of that magnitude has yet addressed safety in the dental world.
“Attendees were awakened and many said we now have some homework to do,” Dr. Casamassimo said after the symposium. “Our speakers talked about medicine and industry and how both have integrated safety and made it a proactive — rather than reactive — consideration in everything they do. The symposium brought to light for many in the audience a false sense of comfort and personal naiveté about the safety of care, as well as assumptions made about the institutions and organizations many believed were watching out for patients and the profession. There was probably a lot of thoughtfulness on the trip home.”
Ideas for improvement
Dr. Casamassimo agreed with Dr. Meeske that the dental profession could learn things from the medical community, including a confidential and anonymous registry meant not to be punitive, but educational for others to avoid repeating preventable harms and risks. One should not have to personally experience an adverse event to be able to avoid it in the future. There is wisdom in learning collectively from the experience of others, he said.
Accountability, transparency and proactiveness are key, Dr. Casamassimo said, rather than sweeping things under the rug, which only invites further preventable harm to creep in.
He pointed out that oral surgeons have begun to create a national registry so that others can learn from and avoid making errors. In addition, pediatric dentists, radiologists, dental anesthesiologists and particularly those in public health settings are actively moving towards embracing routine safety measures.
“Medicine saw itself as very safe until it looked deeper,” Dr. Casamassimo said. “While we don’t believe that morbidity or mortality associated with dental care is large, we really do not know, and that is the problem. Medicine’s awakening to its darker side has led to an even better understanding of preventable errors, reporting of events and a system of prevention and monitoring is built into medical care. Everyone has benefited. Dentistry needs a system to identify problems and translate that knowledge to effective prevention.”
Resolution 78H-2019 was a good start, but there is much more to be done, Dr. Casamassimo said, including instruction at the earliest levels.
“A culture of safety begins with the education of our members,” he said. “The dental education system has its hands full just trying to teach all that is dentistry in the 21st century, but it is really where a safety culture should begin. We don’t do a great job in safety education or in teaching continuous quality improvement, which go hand in hand in practice. Once in practice, a dentist needs to address safety as integral to every aspect of his or her care. It is no longer enough to provide quality, evidence-based care. Quality care means we must integrate consideration of short- and long-term consequences of care for patients and what it took to get there. The process of providing care must also consider its effects on ourselves and our staff, both short- and long-term. For example, we do a very good job with radiation hygiene and infection control, but we don’t know the effects of dozens of exposures to strong sterilization agents for years on our staff.”
Systems, not dentists
Dr. Charles Czerepak, an Illinois-based pediatric dentist, is an attending at Ann and Robert H. Lurie Children's Hospital of Chicago and a member of CAAP’s Medicaid Provider Advisory Committee. He wasn’t quick to criticize his colleagues, though he argued that things have to change. Like Dr. Meeske, he attended the safety symposium that Dr. Casamassimo chaired.
“I get a little squeamish saying that dentistry has fallen behind the medical community in terms of patient safety,” said Dr. Czerepak, a former trustee on the board of the American Academy of Pediatric Dentistry. “Our profession has always held safety as the highest priority. What happened is that the medical community began to look at safety from a different perspective and developed a new paradigm of thinking.”
Systems, not practitioners, are largely to blame, Dr. Czerepak said.
“The thought process is that even good physicians and dentists make mistakes,” he said. “To lower the incidence of errors, one should examine the systems that envelop the practitioner. Making the protocol safer requires examination and inquiry. After reviewing the adverse outcome and suspected causes, adjustments to existing protocols are made and the care delivery team learns about the new processes. Simply stated, feedback loops are established so that the providers can learn from their peers and prevent committing the same error. This is prevention at its best.”
Dr. Czerepak said that dentists may choose not to publicize errors or mistakes they’ve made, but he argued that paradoxically, being transparent doesn’t erode trust between the patient and dentists; it actually enhances it, as shown by experiences in the medical field, he said.
“I’m not saying that dentistry isn’t safe, but this is something we can bring into the way we practice,” Dr. Czerepak said, who added that safety and quality improvement are almost synonymous in medicine.
Dr. Casamassimo summed up why be believes dentistry must ultimately prioritize safety and talk about it openly.
“Pull your heads out of the sand and be honest about the things you can do better,” he said. “In medicine, just good handwashing on a consistent basis has reduced transmitted infections dramatically within hospitals. Look at your complication rates — in medicine, complication rates are not accepted but are seen as opportunities for improvement. Consider looking at what you do in a systematic way. With 80 percent of us in solo practice, we have a long way to go to collect, analyze and use patient care data like medicine does. Finally, if you haven’t established a practice culture in which your staff can tell you about problems without fear of retribution or ridicule, you are at risk. Practices in which the dentist and staff are aligned in protecting patients and themselves are far more likely to avoid minor and even catastrophic events.”
He concluded: “Organized dentistry has nothing to fear from looking at itself with a critical eye because ultimately patients and dentists benefit.”