Policy on Patient Safety
The American Academy of Pediatric Dentistry (AAPD) recognizes patient safety as an essential component of quality oral health care for infants, children, adolescents, and those
with special health care needs. The AAPD encourages dentists to consider thoughtfully the environment in which they deliver health care services and to implement practices to improve patient safety. This policy is not intended to duplicate safety recommendations for medical facilities accredited by national commissions such as The Joint Commission or those related to workplace safety such as Occupational Safety and Health Administration.
This document is a revision of the policy developed by the Council on Clinical Affairs and adopted in 2008 and revised in 2013. This policy is based on a review of current dental and medical literature, including search of the PubMed®/MEDLINE database using the terms: patient safety AND dentistry, fields: all; limits: within the last 10 years, humans, English. Eight hundred twenty-two articles met these criteria. Papers for review were chosen from this list and from the references within selected articles.
All health care systems should be designed to provide a practice environment that promotes patient safety.1 The World Health Organization (WHO) defines patient safety as
“the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum.”2 The most important challenge in the field of patient safety is prevention of harm, particularly avoidable harm, to patients during treatment and care.2 Dental practices must be in compliance with federal laws that help protect patients from preventable injuries and potential dangers such as the transmission of disease.3-5 Laws help regulate hazards related to chemical and environmental factors (e.g., spills, radiation) and facilities (e.g., fire prevention systems, emergency exits).6 AAPD best practices and oral health policies provide additional information regarding the delivery of safe pediatric dental care.7-18 Furthermore, state dental practice acts and hospital credentialing committees are intended to ensure the safety of patients and the trust of the public by regulating the competency of and provision of services by dental health professionals.19-21
Patient-centered health care systems that focus on preventing errors are critical to assuring patient safety.21,22 Some possible sources of error in the dental office are miscommunication, interruptions, stress, fatigue, failure to review the patient’s medical history (e.g., current medications, allergies), and lack of standardized records, abbreviations, and processes.1,21,23 Treating the wrong patient or tooth/surgical site, delay in treatment, disease progression after misdiagnosis, inaccurate referral, incorrect medication dosage ordered/administered, breach in sterilization, and unintentional swallowing, aspiration, or retention of a foreign object are examples of patient safety events that occur in dentistry.24-28 Adverse events may be classified in terms of severity of harm (e.g., none, mild, moderate, severe, death).29
Standardized processes and workflows help assure clerical and clinical personnel execute their responsibilities in a safe and effective manner.23 Policy and procedure manuals that describe a facility’s established protocols serve as a valuable training tool for new employees and reinforce a consistent approach to promote safe and quality patient care.23 Identifying deviations from established protocols and studying patterns of occurrence can help reduce the likelihood of adverse events.7
Safety checklists are used by many industries and healthcare organizations to reduce preventable errors.31,32 Data supports the use of procedural checklists to minimize the occurrence of adverse events in dentistry (e.g., presedation checklist).33-35 In addition, order sets, reminders, and clinical guidelines built into an electronic charting system may improve adherence to best practices.28
Reducing clinical errors requires a careful examination of adverse events23,28,30 and near-miss events22,36. In a near-miss event, an error was committed, but the patient did not experience clinical harm.22,36 Detection of errors and problems within a practice or organization may be used as teaching points to motivate changes and avoid recurrence.37 A root cause analysis can be conducted to determine causal factors and corrective actions so these types of events may be avoided in the future.31,38,39 Embracing a patient safety culture demands a non-punitive or no-blame environment that encourages all personnel to report errors and intervene in matters of patient safety.22,38 Alternatively, a fair and just culture is one that learns and improves by openly identifying and examining its own weaknesses; individuals know that they are accountable for their actions, but will not be blamed for system faults in their work environment beyond their control.39 Evidencebased systems have been designed for healthcare professionals to improve team awareness, clarify roles and responsibilities, resolve conflicts, improve information sharing, and eliminate barriers to patient safety.40-42
The environment in which dental care is delivered impacts patient safety. In addition to structural issues regulated by state and local laws, other design features should be planned and periodically evaluated for patient safety, especially as they apply to young children. Play structures, games, and toys are possible sources for accidents and infection.43,44
The dental patient would benefit from a practitioner who follows current literature and participates in professional continuing education courses to increase awareness and knowledge of best current practices. Scientific knowledge and technology continually advance, and patterns of care evolve due, in part, to recommendations by organizations with recognized professional expertise and stature, including the American Dental Association, The Joint Commission, WHO, Institute for Health Improvement, and Agency for Healthcare Research and Quality. Data-driven solutions are possible through documenting, recording, reporting, and analyzing patient safety events.26,46,47 Continuous quality improvement efforts including outcome measure analysis to improve patient safety should be implemented into practices.28,45 Patient safety incident disclosure is lower in dentistry compared with medicine since a dental-specific reporting system does not exist in the United States.47 Identifiable patient information that is collected for analysis is considered protected under the Health Insurance Portability and Accountability Act (HIPAA).48,49
To promote patient safety, the AAPD encourages:
- Patient safety instruction in dental curricula to promote safe, patient-centered care.
- Professional continuing education by all licensed dental professionals to maintain familiarity with current regulations, technology, and clinical practices.
- Compliance and recognition of the importance of infection control policies, procedures, and practices in dental health care settings in order to prevent disease transmission from patient to care provider, from care provider to patient, and from patient to patient.2-4
- Routine inspection of physical facility in regards to patient safety. This includes development and periodic review of office emergency and fire safety protocols and routine inspection and maintenance of clinical equipment.
- Recognition that informed consent by the parent is essential in the delivery of health care and effective relationship/communication practices can help avoid problems and adverse events. The parent should understand and be actively engaged in the planned treatment.
- Accuracy of patient identification with the use of at least two patient identifiers, such as name and date of birth, when providing care, treatment, or services.
- An accurate and complete patient chart that can be interpreted by a knowledgeable third party.13 Standardizing abbreviations, acronyms, and symbols throughout the record is recommended.
- An accurate, comprehensive, and up-to-date medical/ dental history including medications and allergy list to ensure patient safety during each visit. Ongoing communication with health care providers, both medical and dental, who manage the child’s health helps ensure comprehensive, coordinated care of each patient.
- A pause or time out with dental team members present before invasive procedure(s) to confirm the patient, planned procedure(s), and tooth/surgical site(s) are correct.
- Appropriate staffing and supervision of patients treated in the dental office.
- Adherence to AAPD recommendations on behavior guidance, especially as they pertain to use of advanced behavior guidance techniques (i.e., protective stabilization, sedation, general anesthesia).
- Standardization and consistency of processes within the practice. A policies and procedures manual, with ongoing review and revision, could help increase employee awareness and decrease the likelihood of untoward events. Dentists should emphasize procedural protocols that protect the patient’s airway (e.g., rubber dam isolation), guard against unintended retained foreign objects (e.g., surgical counts; observation of placement/removal of throat packs, retraction cords, cotton pellets, and orthodontic separators), and minimize opportunity for iatrogenic injury during delivery of care (e.g., protective eyewear).
- Minimizing exposure to nitrous oxide by maintaining the lowest practical levels in the dental environment. This includes routine inspection and maintenance of nitrous oxide delivery equipment as well as adherence to clinical recommendations for patient selection and delivery of inhalation agents.
- Minimizing radiation exposure through adherence to as low as reasonably achievable (ALARA) principle, equipment inspection and maintenance, and patient selection criteria.
- All facilities performing sedation for diagnostic and therapeutic procedures to maintain records that track adverse events. Such events then can be examined for assessment of risk reduction and improvement inpatient safety.
- Dentists who utilize in-office anesthesia providers take all necessary measures to minimize risk to patients. Priorto delivery of sedation/general anesthesia, appropriate documentation shall address rationale for sedation/general anesthesia, informed consent, instructions toparent, dietary precautions, preoperative health evaluation, and any prescriptions along with the instructions given for their use. Rescue equipment should have regular safety and function testing and medications should not be expired. The dentist and anesthesia providers must communicate during treatment to shareconcerns about the airway or other details of patientsafety.
- Ongoing quality improvement strategies and routine assessment of risk, adverse events, and near misses. A plan for improvement in patient safety and satisfaction is imperative for such strategies.5,6
- Comprehensive review and documentation of indication for medication order/administration. This includes a review of current medications, allergies, drug interactions, and correct calculation of dosage.
- Promoting a culture where staff members are empowered and encouraged to speak up or intervene in matters of patient safety.
- Bailey E, Tickle M, Campbell S. Patient safety in primary care dentistry: Where are we now? Br Dent J 2014;217(7):333-44.
- World Health Organization. Patient safety: makinghealth care safer. Geneva: World Health Organization; 2017 License CC BY-NC-SA 3.0 IGO. Available at: “http://apps.who.int/iris/bitstream/handle/10665/255507/;jsessionid=A2E0196DF284A670341F5FFB6DA4EF41?sequence=1”. Accessed August 21, 2018. (Archived by WebCite® at: “http://www.webcitation.org/71qPk9eTT)
- Boyce JM, Pittet D, Healthcare Infection Control PracticesAdvisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Available at: “http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm”. Accessed December 17, 2017. (Archived by WebCite® at: “http://www.webcitation.org/6vmkKjYxM”)
- World Health Organization. WHO guidelines on hand hygiene in health care. Available at: “http://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf.?sequence=1". Accessed August 21, 2018. (Archived by WebCite® at: “http://www.webcitation.org/71qQJvBLF”)
- American Academy of Pediatric Dentistry. Policy on infection control. Pediatr Dent 2017;39(6):144.
- U.S. Dept of Labor, Occupational Safety and Health Administration. OSHA Law and Regulations. Available at: “https://www.osha.gov/law-regs.html”. Accessed December 18, 2017. (Archived by WebCite® at: “http:// www.webcitation.org/6vpmTao5J”)
- American Academy of Pediatric Dentistry. Policy on minimizing occupational health hazards associated withnitrous oxide. Pediatr Dent 2018;40(6):104-5.
- American Academy of Pediatric Dentistry. Use of nitrousoxide for pediatric dental patients. Pediatr Dent 2018;40(6):281-6.
- American Academy of Pediatric Dentistry. Prescribing dental radiographs for infants, children, adolescents, and individuals with special health care needs. Pediatr Dent2017;39(6):205-7.
- American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. Pediatr Dent 2017;39(6):246-59.
- American Academy of Pediatric Dentistry. Protective stabilization for pediatric dental patients. Pediatr Dent 2017;39(6):260-5.
- American Academy of Pediatric Dentistry. Informed consent. Pediatr Dent 2017;39(6):397-9.
- American Academy of Pediatric Dentistry. Monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: Update 2016. Pediatr Dent 2017;39(6):278-307.
- American Academy of Pediatric Dentistry. Use of anesthesia providers in the administration of office-based deep sedation/general anesthesia to the pediatric dental patient. Pediatr Dent 2018;40(6):317-20.
- American Academy of Pediatric Dentistry. Use of local anesthesia in pediatric dental patients. Pediatr Dent 2017;39(6):266-72.
- American Academy of Pediatric Dentistry. Policy on acute pediatric dental pain management. Pediatr Dent 2017;39(6):99-101.
- American Academy of Pediatric Dentistry. Use of antibiotic therapy for pediatric dental patients. Pediatr Dent 2017;39(6):371-3.
- American Academy of Pediatric Dentistry. Pediatric restorative dentistry. Pediatr Dent 2017;39(6):312-24.
- American Association of Dental Boards. Composite - 29th edition (2018). Chicago, Ill.: American Association of Dental Boards; 2018:1-108.
- American Academy of Pediatric Dentistry. Policy on hospital staff membership. Pediatr Dent 2017;39(6):106-7.
- The Joint Commission. 2017 National Patient Safety Goals Ambulatory Care Program. Available at: “https://www.jointcommission.org/assets/1/6/NPSG_Chapter_AHC_Jan2018.pdf”. Accessed June 25, 2018.
- Ramoni RB, Walji MF, White J, et al. From good to better: Towards a patient safety initiative in dentistry. J Am Dent Assoc 2012;143(9):956-60.
- Jadhay A, Kumar S, Acharya S, Payoshnee B, Ganta S. Patient safety practices in dentistry: A review. Int J Sci Study 2016;3(10):163-5.
- Black I, Bowie P. Patient safety in dentistry: Development of a candidate ‘never event’ list for primary care. Br Dent J 2017;222(10):782-8.
- Cullingham P, Saksena A, Pemberton MN. Patient safety: Reducing the risk of wrong tooth extraction. Br Dent J 2017;222(10):759-63.
- Obadan EM, Ramoni RB, Kalenderian E. Lessons learned from dental patient safety case reports. J Am Dent Assoc 2015;146(5):318-26.
- Ensaldo-Carrasco E, Suarez-Ortegon MF, Carson-Stevens A, Cresswell K, Bedi R, Sheikh A. Patient safety incidents and adverse events in ambulatory dental care: A systematic scoping review. J Patient Saf 2016;0(0):Epub ahead of print. Available at: “https://pdfs.semanticscholar.org/
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- American Academy of Pediatrics. Principles of patient safety in pediatrics: Reducing harm due to medical care. Pediatrics 2011;127(6):1199-210. Erratum: Pediatrics 2011;128(6):1212.
- Kalenderian E, Obadan-Udoh E, Maramaldi P, et al. Classifying adverse events in the dental office. J Patient Saf 2017;0(0):Epub ahead of print. Available at: “https://dentistry.ucsf.edu/sites/default/files/event/attachments/E.Kalenderian-EBD%20JC%205-15-18%20Article.pdf ”. Accessed August 29, 2018. (Archived by WebCite® at: “http://www.webcitation.org/72KqqUzml”)
- Hurst D. Little research on effective tools to improve patient safety in the dental setting. Evid Based Dent 2016;17(2):38-9.
- Harden SW, Roberson JB. 8.5 tips for dental safety checklists. Todays FDA 2013;25(6):40-3, 45.
- World Health Organization. Surgical Safety Checklist 2009. Available at: “http://apps.who.int/iris/bitstream/10665/44186/2/9789241598590_eng_Checklist.pdf ”. Accessed August 29, 2018. (Archived by WebCite® at: “http://www.webcitation.org/72Kr6z52T”)
- Bailey E, Tickle M, Campbell M, O’Malley L. Systematic review of patient safety interventions in dentistry. BMC Oral Health 2015;15(152):1-11.
- Saksena A, Pemberton MJ, Shaw A, Dickson S, Ashley MP. Preventing wrong tooth extraction: Experience in development and implementation of an outpatient safety checklist. Br Dent J 2014;217(7):357-62. Erratum in: Br Dent J 2014;217(10):585.
- Pahel BT, Rozier RG, Stearns SC. Agreement between structured checklists and Medicaid claims for preventiv edental visits in primary care medical offices. Health Informatics J 2010;16(2):115-28.
- Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A framework for safe, reliable, and effective care. White Paper. Cambridge, Mass.: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017. Available at: “http://www.ihi.org”. Accessed June 25, 2018. (Archived by WebCite® at: “http://www.webcitation.org/71Ov0TcbO”)
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- Ramoni R, Walii MF, Tavares A, et al. Open wide: Looking into the safety culture of dental school clinics. J Dent Educ 2014;78(5):745-56.
- Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Serv Res 2006;41(4 Pt 2):1690-709.
- Sheppard F, Williams M, Klein V. TeamSTEPPS® and patient safety in healthcare. J Healthc Risk Manag 2013;32(3):5-10.
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- Rathmore MH, Jackson MA. Infection prevention and control in pediatric ambulatory services. Pediatrics 2017; 140(5):1-23.
- American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Policy statement – Prevention of choking among children. Pediatrics 2010; 125(3):601-7.
- Kiersma ME, Plake KS, Darbishire PL. Patient safety institution in U.S. health professions education. Am J Pharm Educ 2011;75(8):162.
- Spera AL, Saxon MA, Yepes JF. Office-based anesthesia: Safety and outcomes in pediatric dental patients. Anesth Prog 2017;64(3):144-52.
- Thusu S, Panasar S, Bedi R. Patient safety in dentistry – state of play as revealed by a national database of errors. Br Dent J 2012;213(E3):1-8.
- American Academy of Pediatric Dentistry. Record keeping. Pediatr Dent 2018;40(6):401-8.
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