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My View: Improving Safety in Dentistry

November 16, 2020

By Robert Bosack, D.D.S., Michael Rollert, D.D.S., Stuart Lieblich, D.M.D., Roy Stevens, D.D.S., and Jason Brady, D.M.D.

The dental profession has taken great strides in patient safety particularly since COVID-19 arrived. From taking patient temperatures, parking lots turned into socially distanced reception areas, and innovative office ventilation strategies to high tech personal protective equipment, dentists have re-embraced their role as safety officers for their patients and practices.

A culture of safety not only includes the culture of COVID-19, but also extends into an opportunity to study less than optimal clinical outcomes and collectively learn from these experiences. Just as we continually evaluate the provision of dental procedures to improve outcomes, we can apply these same principles to patient safety.

We all make mistakes. Such human oversights are known to occur during the delivery of health care. These errors create unsafe conditions and close calls, which can result in various degrees of patient and/or staff injury when circumstances align.

Our medical colleagues and health care institutions are acutely aware of these issues and have responded by actively participating in multiple endeavors to improve the quality and safety of the delivery of health care. They do this by continuously (and confidentially) identifying and evaluating such events in order to find out what happened. Within a collaborative culture, they can identify strategies to improve unsafe conditions, minimize close calls, and prevent patient injury. These efforts have resulted in a multitude of patient safety initiatives, including “time-outs,” checklists, and morbidity and mortality conferences.

Unsafe conditions, close calls and preventable injuries also occur in dentistry. However, in contradistinction to medical care, the clinical practice of dentistry most often takes place in the independent setting of a private practice, where there is little to no collective opportunity to identify, analyze, and improve these patient safety events. As ADA President Dan Klemmedson, D.D.S, M.D., notes, “We are the definition of primary care: diagnosis, education, prevention and clinical care.”1 Each office is a microcosm of health care delivery and should be as motivated as our medical counterparts for continuous safety improvement. Until recently, safety issues have not been openly addressed in dental curriculums.

To this day, this topic is largely absent from continuing education podiums and widely circulated dental publications. Being in our individual practices does not readily translate to a shared learning experience, such as complication conferences held in the hospital setting.

How has medicine evolved and how can dentistry adopt this culture of safety?

The U.S. government, responding to the issues of preventable patient injuries and poor outcomes, created the Agency for Healthcare Research and Quality (AHRQ) under the Department of Health and Human Services in 1999. Its impetus was the widely-acclaimed Institute of Medicine report, “To err is human,”2 which noted how human error in health care delivery can lead to adverse outcomes. By reporting errors that occur during the provision of health care (within a confidential climate), all practitioners can learn to recognize the events that led to the error happening without having to personally experience the adverse event themselves; ideally breaking a link in its progression to patient harm, reducing costs and improving outcomes.

In health care settings, there has been a tendency to avoid reporting safety events out of fear of adverse medico-legal or licensing issues. However, it is well recognized that disseminating information (within a restricted platform) about medical errors, especially those involving low frequency/high impact events, could benefit all providers by creating shared learning, allowing others to avoid similar mistakes.

As such, the Patient Safety and Quality Improvement Act of 2005 authorized the creation of Patient Safety Organizations (PSOs), which are uniquely privileged to collect, aggregate, and analyze patient safety reports in order to develop strategies to prevent future patient harm. All health care providers can confidentially submit their health care reports without fear of medico-legal or licensing consequences. Until recently, dentistry has not been part of this process.

Following a rigorous credentialing process in October 2017, the Dental Patient Safety Foundation (DPSF) was officially listed as a PSO (P0198) and now is active in receiving reports, providing shared learning, and improving safety across all aspects of dentistry. The DPSF mission is to support a culture of safety in dentistry. It is the only credentialed PSO with a dental-only focus.

Cases entered via an online reporting tool by dental practitioners are known as patient-specific work products (PSWP). The specific information is then de-identified by the PSO board (according to federal guidelines), so that a case report or other promulgation of information can be disseminated to the profession. Through this collection of case reports, shared learning, without the threat of blame or other consequences, can occur with the goal of improving patient safety.

What can dental providers do to enhance safety in dental practice?

Dental colleagues are encouraged to learn from each other by self-reporting using the confidential reporting online tool. The DPSF collects case information regarding patient safety events. These are:

• Incidents: patient safety events that reach a patient whether or not harm occurs.
• Near misses (close calls): safety events that do not reach the patient.
• Unsafe conditions: circumstances that increase the possibility of the occurrence of an incident or a near miss.

Cases reported to the DPSF are entirely protected from discovery from medico-legal or licensing agency inquiries. The goal of the AHRQ is to encourage self-reporting. This is vital to improving the safe practice of dentistry. It is important to note that reporting to the DPSF does not absolve the practitioner from reporting to state boards of dentistry or other agencies depending on individual state laws. A DPSF report is still encouraged to be made in these cases, but state law needs to be followed as well.

The DPSF is a nonprofit entity, totally independent of all other professional organizations. The Foundation trusts that organized dentistry will appreciate the value of its mission to improve patient safety and offer tangible support. There are no costs for practitioners to subscribe to the site so that one can be alerted when new cases are posted. Dentists are encouraged to register at dentalpatientsafety.org and subscribe to receive safety reports. Past case reports are archived and available for review as well.

Safety is measured by the number and intensity of such behaviors practiced by the profession overall and not by measuring outlier frequency. The DPSF is one tool in this process. Did you know that cutting a bridge while a patient is receiving higher oxygen concentrations with the delivery of nitrous oxide can cause a fire with direct patient injury? This is an example of cases published by the DPSF3; yet patient fires with injury continue to occur in dental practices due to lack of information dissemination. By being part of the solution and reporting events to the DPSF, the profession can improve outcomes via shared learning.

The DPSF supports the ADA’s mission of a culture of safety in dental practice. There is no downside to this endeavor. Our profession’s reputation will be enhanced, our members will have greater opportunity for success, and our patients will continue to receive the highest standard of dental care in the world. Please log on to the DPSF website, subscribe to receive available case reports, review them with your staff and encourage your team to openly discuss and implement safe practice measures.

The authors are on the Board of Directors at the Dental Patient Safety Foundation: Robert Bosack, D.D.S., chair; Michael Rollert, D.D.S., vice chair; Stuart Lieblich, D.M.D., secretary/treasurer; Roy Stevens, D.D.S.; Jason Brady, D.M.D.

1.    Ganski K. Dr. Daniel J. Klemmedson discusses passion for dentistry, journey to ADA presidency. ADA News. August 14, 2020. Available at: https://www.ada.org/en/publications/ada-news/2020-archive/august/dr-daniel-j-klemmedson-discusses-passion-for-dentistry-journey-to-ada-presidency. Accessed September 7, 2020.
2.    Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC, National Academies Press; 1999.
3. Dental Patient Safety Foundation. Shared learning from the Dental Patient Safety Foundation reporting tool: case 2017.12A—patient fire during dental care. Available at: https://www.dentalpatientsafety.org/wp-content/uploads/2018/01/Case_2017.12A_Patient_Fire.pdf. Accessed September 2, 2020.