Lessons learned from dental patient safety case reports

Abstract

Background: Errors are commonplace in health care, including dentistry. It is imperative for dental professionals to intercept errors before they lead to an adverse event and to mitigate their effects when an adverse event occurs. This requires a systematic approach at both the profession level, encapsulated in the Agency for Healthcare Research and Quality's patient safety initiative framework, as well as at the practice level, in which crew resource management is a tested paradigm. Supporting patient safety at both the profession and dental practice levels relies on understanding the types and causes of errors, which have not been well studied.

Methods: The authors performed a retrospective review of dental adverse events reported in the literature. Electronic bibliographic databases were searched, and data were extracted on background characteristics, incident description, case characteristics, clinic setting where adverse event originated, phase of patient care that adverse event was detected, proximal cause, type of patient harm, degree of harm, and recovery actions.

Results: The authors identified 182 publications (containing 270 cases) through their search. Delayed treatment, unnecessary treatment, or disease progression after misdiagnosis was the largest type of harm reported. Of the reviewed cases, 24.4% of those patients involved in an adverse event experienced permanent harm. One of every 10 case reports reviewed (11.1%) reported that the adverse event resulted in the death of the affected patient.

Conclusions: Published case reports provide a window into understanding the nature and extent of dental adverse events; however, the overall dearth of publications on adverse events in the dental literature points to the need for more study.

Practical implications: Siloed and incomplete contributions to dentistry's understanding of adverse events in the dental office are threats to dental patients' safety. Publishing more, and more comprehensive, case reports on adverse events is recommended for dental practitioners.

Keywords: Dental care; adverse events; case reports; patient safety.

Figure 1

Dental adverse event case reports literature review process.

Figure 2

Sample causal tree diagram for a dental adverse event case report. From top to bottom, this figure illustrates how the occurrence of an adverse event (soft-tissue injury, top row) can be traced to its root causes (bottom row) by continuously asking why when performing a root cause analysis.

Figure 3

Hypothetical illustration of incident analyses from aggregated case reports. This figure shows, from left to right, that recurrent latent failures in a dental care delivery system (column 4) become apparent following the review of aggregated case reports (column 2). In this case, the adverse event (foreign body aspiration, column 1) occurred due to active failures (column 3) by frontline providers but can be traced to hidden latent failures in the care delivery system.