Human factors in dentistry: Part 2. Whose fault is a mistake?

It is the author's opinion that all clinicians make mistakes. We are all human beings and therefore, mistakes are inevitable. However, this is not something the dental profession ever feels comfortable acknowledging or discussing with our patients or colleagues when things do go wrong. A dentist who accidentally extracted the wrong tooth or made any error will tell you that they never intended to cause harm or distress to the patient. And yet, it happened. A highly respected restorative consultant once told me, ‘if you haven't made a mistake in dentistry, you haven't seen enough patients.’ And yet, the common misconception in dentistry is that mistakes happen to someone else/inexperienced clinicians, or even that mistakes only happen to ‘bad’ dentists; a statement that is completely untrue.

So how do you avoid making mistakes?

One approach could be to always be prepared, waiting in expectation for the next error to occur. This is not feasible because mistakes are few and far between, thankfully. In Part 1 of the series it was discussed that the use of written standard operating procedures (SOP) checklists for certain complex procedures that are known to carry more risk, such as implant surgery, can help us anticipate and plan appropriately to avoid or minimize the impact of any errors, to a certain degree. Interestingly, we are usually more vigilant when we are doing more complex procedures, such as implant surgery, because they require more focus. Unsurprisingly, we are probably less vigilant when doing something we consider more straightforward, such as a filling or routine extraction, because we have done thousands of these procedures and we often become more complacent, which is one of Dupont's dirty dozen reasons for errors,¹ discussed in Part 1 of the series.

Never events, near misses and duty of candour: what do they mean and when do I need to report one?

The terms ‘never events’, ‘near miss’ and ‘duty of candour’ are commonly used terms within the NHS. The way in which we report these incidents varies greatly depending on whether you work in primary dental care, a hospital setting or community setting. Hospitals use an online platform for ‘adverse incident’ reporting. However, in primary dental care, this reporting system varies between practices, and the onus is very much on the clinician, nurse and their own consciences as to whether they report errors at either a local or national level.

The term ‘never event’ was introduced in 2016 by NHS Improvement.² It included 14 procedures that were described as ‘never events’, meaning that they should never happen within healthcare. These included wrong site surgery and, for dentistry, wrong site dental extraction (excluding deciduous teeth) and wrong site local anaesthetic. However, in May 2019, wrong local anaesthetic blocks for dental procedures were excluded. The removal of the wrong tooth was excluded in February 2021,³ because it had been recognized that systemic barriers to prevent the removal of a wrong tooth were not adequate to prevent these incidents from occurring.

However, by simply adding more safety layers, with an SOP checklist for all dental procedures, we do not make dentistry any ‘safer’ or free from harm because many other factors, such as work load, time pressures and emotional wellbeing, also come into play. There needs to be a balance between the value of safety precautions and unnecessary, additional paperwork required under the guise of ‘extra safety checks.’

The term ‘near miss’ is considered when a mistake that is about to happen, is prevented. These incidents also carry risk because there was a serious risk of harm that could have happened. For example, if the LL5 was almost treated for caries management instead of the intended carious LL4 because the clinician did not check the radiograph before starting, but happened to be questioned by the dental nurse prior to the handpiece touching the wrong tooth. This ‘near miss’ has the potential to cause serious harm if the clinician had not been stopped by the question from the nurse.

Duty of candour⁴ is a term used to explain that all NHS staff have a duty to be open, transparent and honest with patients about all aspects of their care, particularly those which have resulted in a moderate or severe degree of harm. It is a legal and ethical obligation that ensures that patients are involved in their care and are aware when things go wrong. Patients must be kept informed of the next stages, such as how or when an investigation will take place, and what the outcome of the findings of the investigation are.

All dental practices have clinical governance protocols in place, which include adverse incident reporting, as part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.⁵ Therefore, after an adverse event occurs, the practice manager, or the clinician involved, has a statutory duty to inform the patient of what has happened, provide an apology and a full explanation for why the event occurred, as well as the necessary emotional support. This process may occur after a period of fact finding, with the patient being made aware of the situation at the time of the event. Failure to fully inform the patient, or avoid being honest, can result in a GDC fitness-to-practice case.

The theory of how to carry out the duty of candour often differs from the practicality of telling a patient face to face that something has not gone to plan, and the reasons why. Patients are often surprised, angry and upset, and can sometimes threaten litigation, either immediately or after the investigation.

The knowledge that we are all humans and prone to mistakes seems to elude all involved when a mistake has happened and it is time for the investigation, either internal or as part of a formal investigation.

Reporting mistakes: when, how and to whom do I report?

In 2017, Wright et al⁶ reported that at least two errors occur each day within the dental profession, of which 1.4% progressed to an adverse event. How and when to report adverse events and near misses is often confusing for dentists, particularly when reporting systems vary and depend on whether they occur within primary, secondary or community dental care settings.

When a mistake happens that results in harm to a patient, it is important that we, as a profession, know how, when and where to report the mistake. By reporting our mistakes, either locally, within our workplace, or nationally (if appropriate), we can help identify re-occurring themes for the mistakes. When you make a mistake in dentistry, there is sure to be another dentist who has made this same mistake before you, and if we do not report and record this data, there is bound to be another dentist after you who makes the same error. By sharing information, we can learn from one another and support colleagues when errors occur.

Although wrong tooth extraction is no longer considered a ‘never event’ requiring national investigation, it is still worthwhile for ourselves, and our profession, that we have a platform to record our mistakes for lifelong learning among the profession and to minimize the chance of re-occurrence.

How to record and report incidents

Adverse incidents and near misses should be recorded locally in the first instance, using local recording systems within the practice or department. Table 1 provides examples of mistakes that should be reported locally. It is important that both the clinician and the nurse involved in the patient safety incident independently document the details of the event in as close to ‘real-time’ reporting as possible to ensure accuracy of the information. Following a local investigation of the incident and a root cause analysis, any recommended action plans and audits to investigate any patterns of similar incidents should be documented. Furthermore, ‘near misses’ should be reported to the commissioners via the reporting systems available locally.

Certain patient safety incidents may be deemed significant and warrant further escalation. This can be carried out by any member of the team, and may involve reporting to various regulators depending on the nature of the incident. Examples of regulators that may need to be informed of patient safety incidents include the Care Quality Commission (CQC), General Dental Council (GDC), NHS England and the Medicines and Healthcare products Regulatory Agency (MHRA), as well as indemnity organizations. With so many organizations to report to, it can be onerous on the clinician, which emphasizes another significant barrier to reporting.

Patient safety incidents should also be reported nationally on NHS England's national reporting websites,^7,8,9 either by healthcare staff or the general public. Dentists should be encouraged to record all patient safety incidents, including near misses, using their local risk management systems. Until 2021, nationally reported incidents were uploaded to the National Reporting and Learning System (NRLS) to help support national learning among the dental profession. Unfortunately, the NRLS was under-used within the dental profession owing to barriers, such as fear of negative repercussions, lack of awareness of the reporting platform and difficulty of use on a daily basis. Data from the NRLS showed that out of 2 million reported incidents, only 800 were related to dentistry, underpinning the under-reporting of dental mistakes.⁹ Historically, reporting incidents within primary care has always been lower than in secondary care and community dental services.

The NRLS was superseded by the Patient Safety Incident Management System (PSIMS)⁹ in 2021, which created a one-stop reporting, accessing and sharing system for all patient safety incidents, including those in primary, secondary and community dental care settings, with the aim of offering more support for staff across different sectors to record events and provide local and national safety improvement. This single reporting platform will hopefully reduce barriers to reporting. However, the first step in achieving this is to ensure that dental clinicians are informed about its existence at both an undergraduate and postgraduate level.

Reporting mistakes and mishaps in an appropriate timeframe, with open discussions about why and how errors have occurred, introducing lessons learned and how to prevent/minimize such errors re-occurring are essential for professional learning. Figure 1 provides an algorithm of how to report such mishaps.¹⁰

Case 1: wrong tooth extraction

What happened?

Patient A required extraction of the lower left second molar under general anaesthesia. The referring clinician documented the extraction plan and completed a consent form with the patient verbally prior to the patient being seen by an oral surgeon colleague. The documentation said ‘extraction lower left second molar.’ At the time of the procedure, the oral surgeon incorrectly extracted the lower left third molar. The patient and his accompanying guardian were informed once the patient recovered from the general anaesthesia. The clinician involved apologized immediately, and explained that a thorough investigation would be carried out, with the patient updated at every stage of the investigation, both verbally and in writing.

Why did this happen?

During the investigation, it was identified that multiple factors led to this outcome. On the day of the procedure, the patient was consented by a junior dentist rather than the oral surgeon who carried out the procedure. Therefore, the operating clinician had not looked inside the patient's mouth, before the patient was anaesthetized, to confirm which tooth would be extracted. If this had occurred, the operating clinician would realized that the LL6 had previously been extracted and that LL7 had drifted forward.

Furthermore, at the time of the procedure, the computerized radiograph viewing system was not working and the the oral surgeon could not see that the LL6 was missing (Figure 2). The oral surgeon had decided to continue with the dental extraction, despite not been able to see the radiographs, because the patient was already under the effects of the general anaesthetic and considered that it would have been detrimental to the patient to delay the treatment. It was only later that the oral surgeon realized that the wrong tooth was extracted. In this case, the lower left first molar had been extracted many years previously, and there had been mesial drifting of the lower left second molar into the first molar space. The clinician thought the wisdom tooth was in fact the second molar.

The junior dentist who consented the patient had not felt confident to speak up during the procedure, despite being aware that the senior colleague was extracting the wrong tooth. In hindsight he felt that he should have spoken up immediately and acknowledged that it is important to act in the patient's best interests.

The referral letter could have been more prescriptive to include any previously missing teeth. The oral surgeon accepted that carrying out an extraction without an available radiograph was not appropriate, even if the patient would have required rescheduling for the general anaesthetic procedure. The importance of reporting system failures preventing access to computerized radiographs was highlighted.

Management of the situation

The patient and accompanying guardian were both informed immediately after the procedure, and an apology was given. All staff members involved in the incident had a team huddle to de-brief about the incident. All staff involved documented, in their own words, the series of events that led to the incident. Emotional support was given to all staff involved, particularly the junior dentist who consented the patient, and the oral surgeon who extracted the wrong tooth. The clinical lead carried out a thorough investigation into the referral process and introduced a referral template including a chart of missing teeth. All staff were given an opportunity to discuss the case at the following audit and governance meeting. The importance of speaking up when there are doubts or concerns about patient safety or outcomes was highlighted to all staff, especially junior staff, outlining the importance of putting patient's interests first.

To assess whether there were ongoing issues with the computer systems, adverse incident reporting of computer failures were recorded and audited over 3 months. To overcome this problem, copies of radiographs were emailed to operating clinicians prior to theatre lists to ensure there was always access to radiographs.

Protocol changes within the department were initiated so that all operating clinicians were present to confirm consent with junior clinicians and assess the patient intra-orally prior to anaesthesia. Standard operating procedures were also created for all oral surgery extractions under general anaesthesia, and a separate SOP for extractions under local anaesthesia/sedation were created.

Adverse incidents over the following 3 months were audited to assess whether any further changes were necessary. Ongoing emotional support was provided to all involved in the incident, including the patient, who made a formal complaint via the Patient Advisory Liaison Services (PALS) within the Trust. The incident was reported on the hospital adverse incident reporting system, as well as nationally via NRLS for an opportunity for national learning within the profession.

Duponts dirty dozen factors involved in this case

• Lack of communication: between the referring dentist and the oral surgeon, as well as lack of communication between consenting junior dentist and the oral surgeon.
• Lack of resources: ongoing issues with accessing computerized radiographs within operating theatres.
• Stress: the oral surgeon was trying to cope with high patient volume and overbooked theatres, and so was unwilling to cancel the surgery after the patient had already been anaesthetized.
• Complacency: the oral surgeon ‘assumed’ the second molar seen in the mouth was actually the second molar tooth without assessing the possibility of a missing first molar.
• Pressure: the oral surgeon tried to complete treatment as the patient was already anaesthetized.
• Lack of teamwork: the junior dentist did not feeling comfortable to raise his concerns
• Lack of awareness: the junior dentist did not act in the patient's best interest when he knew that the wrong tooth was being removed. The oral surgeon did not step back to assess the situation fully.
• Lack of assertiveness: the junior dentist did not speak up when he knew the wrong treatment was being carried out. have been detrimental to the patient to delay the treatment. It was only later that the oral surgeon realized that the wrong tooth was extracted. In this case, the lower left first molar had been extracted many years previously, and there had been mesial drifting of the lower left second molar into the first molar space. The clinician thought the wisdom tooth was in fact the second molar.
• Norms: the expectation that senior colleagues always know best

Case 2: near miss sodium hypochlorite accident

What happened?

Patient B was undergoing routine extraction of the lower right third molar prior to commencing chemo-radiotherapy for tonsillar squamous cell carcinoma. Following completion of the extraction, the dentist asked the trainee dental nurse for saline to irrigate the socket prior to suturing the area. The dental nurse was inexperienced and did not know where various equipment and materials were stored. Sodium hypochlorite was placed in a syringe and brought to the clinician. Before the irrigant was used intra-orally, the clinician stopped and confirmed the contents of the syringe with the nurse. The procedure was stopped just before the incorrect irrigant was used. The nurse became flustered and ran out of the room feeling overwhelmed and upset. The clinician proceeded to complete the treatment alone, after which he wrote his clinical notes and continued with the next patient. A different dental nurse assisted him for the remainder of the day. No documentation or reporting of the incident occurred and no discussions were had among the team or with the patient.

Why did this happen?

The trainee dental nurse had not been given induction training when she joined the department. She was inexperienced and unfamiliar with the procedure, the environment and other team members. She did not feel she was in a position to question or ask for support from her colleagues because she did not want to be criticized. Additionally, the dentist had not previously worked with the nurse and was unfamiliar with her level of experience. On the day, there had been no discussions regarding what procedures and equipment would be needed, and therefore the nurse felt unprepared. The nurse was not supported by a senior nurse for the procedure, and had no observational experience before being allocated to work independently, which compounded the situation.

The dentist was unaware that this incident was classified as a ‘near miss’ and that it required documentation and investigation locally, and that it could also be reported nationally for lessons to be learned using the NRLS platform. No local audits were carried out to assess the incidence of adverse incidents within the department, and therefore patterns of similar incidents were not detected and rectified before this event.

Management of the situation

An external clinician heard of the ‘near miss’ incident within the department and offered to provide training on human factors at the subsequent audit meeting. There were open discussions among the team around the incident to identify the root causes of why the incident happened. The importance of communication between staff, especially at the start of the morning and afternoon sessions, to brief on what is expected for the day, was highlighted. In-house incident form reporting as well as national reporting was also highlighted, and an incident reporting logbook was created. Induction training for all new staff as well as a new staff handbook was implemented. In addition, an induction period of 2 weeks to allow new nurses to observe and become familiar with protocols before independent practice was agreed.

Finally, in cases of ‘near misses’ it is important to explain what happened to the patient and apologize.

Dupont's dirty dozen factors involved in this case

• Lack of communication: between the dentist and dental nurse, because the nurse did not know where equipment was kept, or how saline was stored compared to sodium hypochlorite. Also lack of communication between senior nurses and the trainee nurse, with inadequate training and mentorship.
• Stress: the dental nurse felt under pressure to perform well, the dentist was under stress to complete the procedure and move onto the next patient waiting outside.
• Complacency: among the team to assume all new trainee nurses would automatically be able to complete tasks independently without mentorship and guidance.
• Lack of teamwork: between junior and senior nurses, and between the dentist and nurse treating this patient.
• Pressure: to complete tasks promptly.
• Lack of awareness: dental nurse not knowing her limitations.
• Lack of knowledge: the dental nurse was not yet qualified and had limited previous experience in the clinical environment. She should not have been practising independently without support.
• Lack of assertiveness: the trainee dental nurse did not feel able to voice her concerns.
• Norms: the attitude within the department was that trainees would be at the same competency levels as qualified nurses and would not complain or raise concerns.

Case 3: incorrect medication given to patient

Patient C was incorrectly prescribed amoxicillin despite having a penicillin allergy. The patient did not take the antibiotics because she was aware of her history of anaphylaxis with penicillin and returned to the dental practice to complain about the mistake.

Why did this happen?

The dentist did not check and update the medical history each time the patient was treated in accordance with the GDC standards' principle for maintaining and protecting the patient's information. The dentist also forgot to check the medical history before prescribing the antibiotics to ensure no contra-indications existed. The patient had been seen initially as an emergency appointment and was an addition to an overbooked Monday morning clinic. The dentist felt time pressure and stress to see the patient quickly, and prescribed antibiotics without a thorough examination and history.

Management of the situation

The dentist apologized and the practice manager explained to the patient that a thorough investigation would be carried out in line with the practice policy. During the internal investigation, the dentist and nurse involved in the patient's care both documented the details of the appointment.

The dentist reported that time pressures and stress were important factors contributing to the issue. Further investigation into the matter, using audit, revealed that the dentist routinely forgot to verbally ask or document any changes in the medical history during appointments. The importance of accurate medical histories and updates was highlighted to all staff and further training was carried out.

Owing to the overbooked clinics, it was decided to dedicate a 15-minute slot for emergency walk-in patients every morning to prevent overbooked clinics and additional pressure on dentists. The ‘near miss’ was documented in the practice incident book, and a full apology was issued to the patient.

Dupont's dirty dozen factors involved in this case

• Distraction: the dentist was not fully focused on the emergency patient owing to other pressures.
• Stress: owing to the overworked situation and time constraints.
• Complacency: owing to not checking and updating medical histories for all patients when providing treatment.
• Lack of awareness: the dentist was unaware of his mistake until the patient returned to complain. If the patient had unknowingly taken the antibiotics and had an anaphylactic reaction, the dentist would have been responsible.
• Fatigue.
• Norms: not following safety protocols or GDC principles.

Case 4: extraction of wrong tooth

Patient D was due to commence orthodontic treatment and required pre-operative extractions of multiple deciduous teeth before fixed orthodontics could commence in the mixed dentition. The peri-apical radiograph and DPT were taken in January 2020, with the patient consented by the orthodontist for ULB extraction as part of the treatment plan, along with other extractions under general anaesthesia. Unfortunately at the time of extraction, 3 months had lapsed since the original radiographs were taken. The ULB had exfoliated in that time and the UL2 erupted. The oral surgeon was unaware of the ULB exfoliation and extracted the UL2 at the time of the general anaesthetic surgery. Once the mistake was realized, the UL2 was reimplanted and splinted with a composite splint to the adjacent tooth for 2 weeks (Figure 3).

Why did this happen?

During the time between finalizing the treatment plan and consent with the orthodontist, the patient had lost the ULB and the UL2 had erupted into its correct position. The oral surgeon felt that the tooth was microdont in nature and continued with the written treatment plan. Furthermore, there was no discussion with the patient or parents about teeth lost since last attendance prior to the general anaesthesia commencing.

Management of the situation

The patient and parents were informed of the incorrect extraction after the procedure. A full explanation and apology was provided with a full investigation carried out within the department. An adverse incident was reported and discussed within the department. At the time, this was considered a ‘never event’ and therefore the full reporting pathway was followed. A LOCSSIP (Local Safety Standard for Invasive Procedures) was introduced (Figure 4). Further changes implemented included having updated treatment plans confirmed with patients on the day of the surgery to include any lost teeth since last attendance within the department.

Dupont's dirty dozen factors involved in this case

• Lack of communication: among patient, parents and oral surgeon. The clinician should have checked before the procedure whether there had been any changes since the patient was last seen.
• Stress: the oral surgeon was trying to cope with a high patient volume.
• Complacency: the oral surgeon assumed the UL2 was the ULB because it was in the same position, and did not expect the ULB to have exfoliated and UL2 to have erupted in the time since the last visit.
• Pressure: the oral surgeon was trying to complete treatment because the patient was already anaesthetized.
• Lack of awareness: the oral surgeon did not realize which tooth was in situ.
• Norms: there was an expectation that the radiographs and treatment plan provided were accurate at the time of the procedure.

Conclusion

Human factors affect the dental profession on a daily basis. The understanding of the role of human factors on clinical practice is fundamental to appreciating how and why things go well, or not, in daily clinical practice. A shift away from the blame culture that exists within NHS dentistry is needed to help those within the profession feel able to disclose and report patient safety incidents to healthcare regulators for local and national learning. The 2020 position paper by the National Advisory Board for Human Factors in Dentistry has created an opportunity for a new way of thinking and managing adverse incidents in dentistry that should empower all within the profession to use mistakes as an opportunity to learn and grow without fear of reprimand from healthcare regulators.