Dental Quality Improvement

It’s easy to make mistakes. Dentists are busy. A lot of patients are seen in the course of a week. Keeping straight who is who, and remembering precise details of someone you last saw a few weeks ago is difficult.

Dental surgeries can also be cognitively demanding, with a lot of things happening at once: a receptionist tells you about a cancellation and asks what you want to do; your vocational trainee wants help with a patient; a colleague comes in to talk to you about an internal referral, and the new nurse you are working with is unfamiliar with your work processes. It can be difficult to focus on one thing.

Unsurprisingly, things go wrong. One common error is the extraction of the wrong tooth. In England, Pemberton and colleagues reviewed three years of data from NHS England, and concluded that extraction of the wrong tooth was the commonest wrong site surgery incident. As all the reports came from hospitals or community trusts, we can reasonably conclude that the numbers recorded were only a proportion of the true number, given that most dental activity happens in general dental practices. This is not a UK-specific problem – it happens all over the world.

At the time of Pemberton’s work, wrong tooth extractions in England were classified as a ‘Never Event’, something that should not occur. Intra-surgical Never Events include wrong site surgery, wrong implant / prothesis, and retained foreign objects post procedure. Dental wrong site extractions fit this definition, and so were recorded along with other ‘Never Events’.

Some argued, however, that dental wrong site extraction should be excluded from Never Events because:

1. The consequences were rarely as severe as with other types of surgery
2. Even if dentists tried hard to avoid them, the events sometimes occurred.
3. Recording wrong site extraction could result in unhelpful blame.

The core argument of proponents for not considering wrong site extraction as a never event is not that wrong site extractions are not errors, but rather that they do not meet criteria for severity and preventability. Definitions are important, and if severity is a key component of a ‘never event’ definition, then this is a reasonable argument. A patient is unlikely to be persuaded by the argument, but recording criteria are important.

On the second point, Sampson (2018) argued that ‘if a provider takes every recommended step to prevent occurrence and an incident still occurs, this argues strongly that the incident was not preventable and therefore not a never event‘. From a Quality Improvement perspective, this is more difficult to fit into a QI framework.

The idea of ‘Zero Defects‘ is not that no error can ever occur, but rather that systematic efforts can be made to reduce the likelihood of them occurring; to identify the error early if it does occur, and to prevent the error then becoming a defect in care. To turn this into a cycle the occurrence of the error should be reviewed, and changes made if required to reduce the likelihood of it happening in the future.

To move this back into dental terms, a Quality Improvement approach to Wrong Site Extraction is to think about the error – selecting the wrong site – and the defect in care – removing the incorrect tooth – and considering how to tackle the issue. Common steps would be:

1. Understand the problem. How often does it happen, when does it happen?
2. Analyse its causes. What contributes to the occurrence of the error?
3. Develop and test countermeasures. Based on the knowledge gained in steps (1) and (2), what can we try to reduce the frequency of the error occurring?
4. Identify ways to intervene if the error occurs. The error is the identification of the wrong site. The defect in care is the extraction of the incorrect tooth. Separating out these two ideas – the dentist has made an error in site identification, and the subsequent extraction of the tooth – means that there are opportunities to intervene. Can the nurse, for example, see what is happening and bring it to the attention of the dentist? This brings in issues of hierarchy and deference, but these are problems that can be tackled.
5. Review any error or defect that does occur. If an error or a defect does occur, go back to Step One, and establish whether there is new learning from it.

NHS England did decide to remove wrong site tooth extraction from their list of Never Events. Their argument was that ‘the available barriers to prevent the removal of wrong teeth are considered not strong enough to prevent this type of incident from occurring in all cases’.

What does contribute to wrong site extraction? Brennan and Shakib summarise the findings of reviews as:

‘Root-cause analysis of wrong tooth removal commonly indicates poor documentation, unclear diagnosis, suboptimal checks and/or cross checking of relevant clinical information, orthodontic extractions, extractions in the mixed dentition, and ambiguity regarding the notation of molar teeth, especially in heavily restored dentition with missing and migrating teeth.’

Some of these causes are clearly preventable. Brennan and Shakib fear that reclassifying wrong site extraction may lead to less focus on its prevention. Looking at some of the commonest causes, they argue that,

‘Miscommunication errors can be reduced by using written terms such as ‘lower right most posterior molar’ to avoid ambiguity. Other methods to improve situational awareness could provide further confirmatory information about restorations, site, or identifiable features. Similarly, notation for orthodontic extractions that emphasises primary or secondary dentition, and placing marks on radiographs and/or the patient, are also helpful.’

In addition, there is evidence that wrong site extraction can be reduced by other means. Educational interventions have an impact, and checklists help when used.

The conflation of learning and blame is a problem. Errors occur for all sorts of reasons, and learning from them is important. Removing wrong site extraction as a never event in England reduces Never Event numbers at a stroke, and there is a plausible argument for their reclassification. The important issues are to keep looking at wrong site extraction whatever their classification, to continue to review incidents, and to test out ways of reducing their incidence.

Photo by cottonbro studio: https://www.pexels.com/photo/a-person-looking-at-xray-image-of-teeth-6502039/

References

Anwar, H. and Waring, D. (2017) “Improving patient safety through a clinical audit spiral: prevention of wrong tooth extraction in orthodontics,” British Dental Journal, 223(1), pp. 48–52. Available at: https://doi.org/10.1038/sj.bdj.2017.586.

Brennan, P.A. and Shakib, K. (2021) “Wrong-site tooth extraction removed from the list of NHS never events – implications for OMFS,” British Journal of Oral & Maxillofacial Surgery, 59(7), pp. 840–842. Available at: https://doi.org/10.1016/j.bjoms.2021.02.021.

Chang, H.-H. et al. (2004) “Effectiveness of an educational program in reducing the incidence of wrong-site tooth extraction,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 98(3), pp. 288–94.

Cullingham, P., Saksena, A. and Pemberton, M.N. (2017) “Patient safety: reducing the risk of wrong tooth extraction,” British Dental Journal, 222(10), pp. 759–763. Available at: https://doi.org/10.1038/sj.bdj.2017.448.

Dargue, A. et al. (2021) “The impact of wrong-site surgery on dental undergraduate teaching: a survey of UK dental schools,” European Journal of Dental Education, 25(4), pp. 670–678. Available at: https://doi.org/10.1111/eje.12645.

Davidson, M, Brennan, P.A. (2019) “Leading article: What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety.” British Journal of Oral and Maxillofacial Surgery, 57 (2019), pp. 407-411.

Jacob, O., Gough, E. and Thomas, H. (2021) “Preventing Wrong Tooth Extraction,” Acta stomatologica Croatica, 55(3), pp. 316–324. Available at: https://doi.org/10.15644/asc55/3/9.

Jan, A. et al. (2019) “The prevalence and causes of wrong tooth extraction,” Nigerian Journal of Clinical Practice, 22(12), pp. 1706–1714. Available at: https://doi.org/10.4103/njcp.njcp_206_19.

McKernon, S.L. et al. (2017) “Incorrect tooth extraction – Never say never?,” Oral Surgery, 10(1), pp. 30–35. Available at: https://doi.org/10.1111/ors.12219.

Pemberton, M.N. et al. (2017) “Wrong tooth extraction: an examination of ‘Never Event’ data,” The British Journal of Oral & Maxillofacial Surgery, 55(2), pp. 187–188. Available at: https://doi.org/10.1016/j.bjoms.2016.05.032.

Pemberton, M.N. (2019) “Wrong tooth extraction: further analysis of “never event” data,” British Journal of Oral & Maxillofacial Surgery, 57(9), pp. 932–934. Available at: https://doi.org/10.1016/j.bjoms.2019.08.004.

Roberts, N., Wordsworth, S. and Stupple, E. (2023) “Why are surgical never events still occurring: A Delphi study research sample across NHS England operating theatres,” Perioperative Care and Operating Room Management, 32. Available at: https://doi.org/10.1016/j.pcorm.2023.100327.

Saksena, A. et al. (2014) “Preventing wrong tooth extraction: experience in development and implementation of an outpatient safety checklist,” British Dental Journal, 217(7), pp. 357–362. Available at: https://doi.org/10.1038/sj.bdj.2014.860.

Sampson, V. (2018) “Should wrong extraction site be classed as a never event?,” British Dental Journal, 225(4), pp. 291–292. Available at: https://doi.org/10.1038/sj.bdj.2018.649.