Review of never and serious events related to dentistry 2005-2014.

Abstract

Aims To review never and serious events related to dentistry between 2005-2014 in England.Methods Data from the National Reporting and Learning System (NRLS), with agreed data protection and intelligence governance, was used - snapshot view using the timeframe January 2005 to May 2014. The Strategic Executive Information System (STEIS) database was reported separately for 2012-2013 and 2013-2014. The free text elements from the database were analysed thematically and reclassified according to the nature of the patient safety incident (PSI).Results From the NRLS dataset, 32,263 patient safety events were reported between 1 January 2005 and 30 May 2014. Never events (NEs) from STEIS files were all wrong site extractions (WSS), reported separately for 2012-2013 and 2013-2014. The total number was 43.36 of the 43 PSIs were WSS involving: multiple extractions and bimodal age distribution (very young or over 60 years). Forty-seven percent of never events resulted in no harm, 20% low harm, 7% moderate harm, less than 1% severe harm and 23 deaths over this period (five of which were not related to dentistry). Serious harm and death risk factors included: care in an acute trust ward, peri oncological, reconstructive surgery (OMFS), patient age over 67 years with concurrent medical complexity (Ischaemic heart disease). Sixty percent of PSIs occurred in OS/OMFS in acute trust inpatients and 20% in primary care. From STEIS 2012-2013, 21 WSS were reported of which 50% occurred in oral surgery (OS) or oral and maxillofacial surgery (OMFS). The reported sites were 45% in operating theatre and 42% in dental surgery.Conclusion Incidences of iatrogenic harm to dental patients do occur but their reporting is not widely carried out. Improved awareness and training, simplifying the reporting systems improved non-punitive support by regulators would allow the improvement of patient safety in dental practise.