Dental Quality Improvement

Dental surgeries are risky places. The nature of dental interventions means that complications will arise from time to time no matter how good the practice: we take time to explain the potential complications and the pros and cons of treatments so that patients can make informed decisions.

In other cases, the risk can be reduced or avoided altogether. Patient safety refers to ‘the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum’. No one working in dentistry is going to oppose reducing risk, but how do you do it?

Ronald Zentz, a Chicago-based dentist, summarised previous advice in a recent paper. He notes the importance of careful patient assessment, and consideration of risk in care plans, which would be hard to argue with, but he also notes the importance of patient safety being a focus for the wider patient team.

He recommends:

• Taking a team approach.
• Creating a team or service culture that allows good communication and constructive feedback.
• Including patient safety and risk management as items in team meetings.
• Having a team patient safety lead.
• Accessing learning, such as patient safety and risk management courses, and training designed to support team work.
• Creating local processes for reviewing near misses and adverse events and sharing information where possible.

Of course this is all easier said than done. We have noted the challenges to sharing information on quality in dental care in previous posts and Dr Zentz acknowledges the same issues such as limited data collection, and worries about reputational risk. This should not preclude active consideration of patient safety within teams, however, and Quality Improvement theory has some useful concepts that teams can apply.

These include:

1. Reducing risk of an error as far as possible. This involves considering predictable risks and working out how to minimise the likelihood of their occurrence. Wrong site extraction is a good example of this. It is the commonest wrong site surgery recorded by NHS England, although given the frequency of extractions in hospitals and in general dental practice, this may not be surprising. There are good ways of reducing the risk of wrong site extraction, and several organisations publish guidance on ways of tackling it, including sharing examples of good practice. Agreeing standard procedures for this in a practice reduces the potential for confusion for nurses if dentists in the same practice or team take different approaches to error prevention.
2. Creating ways of identifying an error if it occurs. No system is perfect. Mistakes will happen. The classic advice, ‘if you are in a hole, stop digging’, applies here. If you think about an error as the mistake, then the defect is the impact that results from the error. If the error can be identified early, it is often possible to prevent the defect in care occurring, or at least to minimise it. Taking the wrong site surgery example above, if the dentist confuses the site, the nurse in the room who has access to the records may be able to draw the dentist’s attention to it, and so prevent any harm occurring. For this to work, it has to be as easy as possible to identify the error – in this case by having the notes available, and the nurse checking them – and the clinical team must have a relationship that allows challenge.
3. Take time to understand what happened, and why. Mistakes are expensive and distressing for both the dental team and the patient. No one wants a defect in care, but when an error or a defect occurs, it makes sense to take time to understand what happened. ‘Individual error’ is usually the immediate reaction in dentistry, but problems occur in a context. Time pressures, staff who don’t know one another, record keeping problems, unclear patient histories, equipment problems and so on can all contribute. Team relationships, where staff feel unable to point out a potential problem, can also contribute. Undertaking a root cause analysis of the problem helps those involved to take stock of what happened, and to think about what might be done to reduce the likelihood of it happening again. As Ronald Zentz noted, the more learning that can be shared within the team, and between teams, the better.
4. Developing and applying countermeasures. Identifying causes is great, but the point of it is to then make changes that reduce the chance of the same thing happening again. Making improvements that are then applied across the team mean that everyone does not have to make the same mistake for themselves: they can benefit from the experience of others. This then feeds back into step one, with these new measures being applied to reduce the chance of the error occurring.

Safety is an important component of quality in dental care. Taking a structured approach to the reduction of error and the prevention of defects helps dental teams by both giving a process by which to consider problems, and by reducing the likelihood of repetition.

Photo by Andrea Piacquadio at pexels.com