Removing these dental mistakes from never events has nothing to do with not taking them seriously.
AI Overview about why wrong extractions were removed as a never event
“The NHS removed wrong tooth extractions from the list of Never Events on April 1, 2021 because the barriers to prevent them were not strong enough: Lack of standardization in tooth site marking.”
Never Events are serious patient safety incidents that can be prevented with strong systemic barriers. However, the NHS determined that the barriers to prevent wrong tooth extractions were not sufficient.
“While wrong tooth extractions are no longer considered Never Events, they are still classified as Patient Safety Incidents and should be reported and managed accordingly.”
Some risk factors for wrong tooth extractions include:
- Human error
- Miscommunication
- Inadequate referral
- Being overworked and rushed
- Lack of focus or experience
- Being distracted
From The Royal College of Surgeons of England
Wrong site tooth extraction: no longer a never event
Implications for dental professionals
Although wrong site tooth extraction has been removed from the never events list, it still remains an incident with significant and potentially harmful consequences. As well as any physical and psychological impact on the patient’s welfare, wrong site tooth extractions can also be costly, and cause fundamental long-term stress for the clinician and organisation involved.
Between 2004 and 2014, 51 claims for wrong tooth extractions were recorded by NHS trusts in England, with the successful claims costing the NHS over £340,000.
Data from the Dental Defence Union revealed that between 2006 and 2011, each settled claim cost on average £7,300 plus legal fees.
There could potentially be an increase in wrong site tooth events if clinicians are now less concerned about the consequences as these events are no longer identified or labelled as a never event. Dental professionals should be aware of the potential risk factors, which include differences in dental notation, multiple carious teeth, orthodontic extractions, only two molar teeth being present in a quadrant, extractions in the mixed dentition, time lag between treatment plan and extraction date, and human errors such as miscommunication, distraction, complacency, stress, fatigue and teamwork as well as lack of resources, awareness, knowledge and assertiveness.
It is important to recognise that it is rare for only one of these risk factors to be involved in the incident. The Swiss cheese model illustrates how hazards are prevented by a number of barriers or defences.12 Each barrier has a ‘hole’ or weakness such as one of the risk factors described. An adverse incident is very likely to occur if all the holes are aligned, showing how there is usually a combination of risk factors that results in a wrong site tooth extraction.
Recommendations
It is clear that despite having LocSSIPs and safety protocols, wrong site tooth extractions still occur. However, best practice should still be followed to minimise risk, as suggested in the Faculty of Dental Surgery toolkit. Additionally, methods to reduce human error should be introduced and implemented in organisations, including in primary dental care. Strategies proposed by Pemberton include:13
……..
(there follows a table of protocols )
https://publishing.rcseng.ac.uk/doi/full/10.1308/rcsfdj.2021.42