This topic covers an approach that focuses on the underlying system flaws that encourage errors to take place, rather than placing blame on a solo event.
This document, created by the U.S. Department of Health and Human Services, is an entry of the AHRQ Patient Safety Network “Patient Safety 101” series. It states “...human error is inevitable, especially in systems as complex as health care… The systems approach holds that efforts to catch human errors before they occur or block them from causing harm will ultimately be more fruitful than ones that seek to somehow create flawless providers.”
Lessons Learnt from Dental Patient Safety Case Reports is a review of the literature related to cases of adverse events involving dental patients. Delayed and unnecessary treatment/disease progression after misdiagnosis was the largest type of harm reported. 24.4% of reviewed cases were reported to have experienced permanent harm. One of every ten case reports reviewed (11.1%) reported that the adverse event resulted in the death of the affected patient.
Inspired by the Institute for Healthcare Improvement’s (IHI) global and outpatient trigger tool, the authors of An Adverse Event Trigger Tool in Dentistry: A New Methodology for Measuring Harm in the Dental Office introduce a Dental Clinic Trigger Tool and propose a directed records review approach as a promising method for identifying adverse events.
Systematic Review of Patient Safety Interventions in Dentistry
Systematic Review of Patient Safety Interventions in Dentistry presents an evaluation of the scientific literature on patient safety interventions in dentistry. Key findings included that the only interventions in dentistry that reduce or minimize adverse events are surgical safety checklists and concluded that further research into patient safety in dentistry is needed across several domains: epidemiological, conceptual understanding and patient and practitioner involvement.
Reducing Prescribing Error: Competence, Control, and Culture
Reducing Prescribing Error: Competence, Control, and Culture highlights the most important interventions in three domains, competence, control, and culture, to reduce prescribing errors. Key opportunities to reduce errors include improvements in training, testing competence, implementing controlled prescription systems in which prescribers perform, and supporting organizational cultures that believe that prescribing is a complex, technical act, and that it is important to get it right.
The Dangers of Dental Devices as Reported in the Food and Drug Administration Manufacturer and User Facility Device Experience Database
The authors of the Dangers of Dental Devices as Reported in the Food and Drug Administration Manufacturer and User Facility Device Experience Database summarize their analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database on effectiveness of identifying adverse events associated by dental device. They conclude that MAUDE had substantial limitations that prevent it from being the broad-based patient safety sentinel the profession requires.
TeamSTEPPS Dental Module
TeamSTEPPS is an evidence-based set of teamwork tools, aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals. The TeamSTEPS dental module consists of videos (~5 minutes each) showing how dental staff can integrate TeamSTEPPS in their practices.
UTHSCH Dental School Dental Patient Safety Training Modules
The UTHSCH Dental School Dental Patient Safety Training Modules are designed to teach processes of gathering data, interpreting data, coming up with triggers for more focused data gathering, root-cause analysis, and implementing systems to prevent adverse events. The modules are combined with quizzes for self-assessment and calibration. Visit https://uth.instructure.com/courses/16371 to view.
Adaptation of Airline Crew Resource Management Principles to Dentistry
In “Adaptation of Airline Crew Resource Management Principles to Dentistry”, the authors propose strategies such as risk analysis for dentistry. They provide a dental checklist divided into appointment review, pre-procedure, procedure, pre-dismissal and post-dismissal to enhance error detection.
MHA Best Practice Recommendations to Reduce Medication Errors
Two basic principles make up the foundation of the best practice recommendations in “MHA Best Practice Recommendations to Reduce Medication Errors” by the Massachusetts Hospital Association: 1) the establishment of a systems-oriented approach to patient safety; and, 2) the creation of a safe environment that supports open dialogue about errors, their causes, and strategies for prevention. Click here to view. This resource came about through the collaboration of the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association during their state-wide initiative to prevent medical errors and improve patient safety between 1997-1999.
From Good to Better; Toward a Patient Safety Initiative in Dentistry
From Good to Better; Toward a Patient Safety Initiative in Dentistry outlines the elements needed to minimize patient safety hazards. The authors describe where dentistry stands today and what the road ahead may look like. “Successful implementation of the patient safety initiative will take continuous commitment on the part of all members of the dental care team, iterative betterment, and the generation and sharing of best practices and evidence within our field.”
Feasibility of Electronic Health Record–Based Triggers in Detecting Dental Adverse Events
Feasibility of Electronic Health Record–Based Triggers in Detecting Dental Adverse Events summarizes the study of a selection of patient charts using triggers and assessment through calibrated reviews. The authors conclude that EHR triggers may be an efficient method to identify dental patient adverse events.