Errors and adverse events in dentistry – a review

Abstract

As dental professionals we must change the way we think about error. By adopting a more positive, constructive approach, centred around analysing why errors happen, we can then accept our vulnerability and design systems and protocols to prevent errors from occurring. Errors are inextricably linked to human behaviour. Human factors in healthcare are concerned with ensuring patient safety through promoting efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. Essentially, this embraces standardization and involves examining and designing out error. Health Education England has highlighted education in ‘human factors’ as a priority workstream, however, there are many impediments to progress as system changes are slow and difficult to implement. This effectively means that, at present, it is up to individual practitioners to introduce the concept of human factors into their practices. A number of factors have been identified that are critical to reducing error, namely teamwork, communication, leadership and fatigue. Furthermore, a number of strategies have been implemented in secondary care to help reduce the risk of error, including effective leadership, specific policy and procedure, and monitoring and measuring compliance. The majority of the causes of error are related to human factors rather than technical ability or inadequate knowledge. This has major implications for primary care practice, as currently we are concentrating our professional development on the use of technology and our intellectual capabilities, rather than implementing education within, and the development of, human factors. It is our recommendation that human factors form part of our undergraduate teaching and core CPD (Continued Professional Development). CPD/Clinical Relevance: There needs to be a paradigm shift from a culture of blame to a just culture, where it is accepted that, despite our experience, character and talents, we are going to commit errors.