Dental News - British researchers outline list of 15 never events for dentists to follow

Dental Tribune UK

Fri. 8. June 2018

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LONDON, UK: A team of researchers has developed a list of 15 so-called never events for dentistry. These are serious patient safety incidents that should be avoided through appropriate preventative measures. Though there is agreement on what classifies as a never event in the field of medicine, there was no such consensus in dentistry previously.

Researchers from the University of Edinburgh, Cardiff University and King’s College London in the UK developed the list of never events after consultation with an international panel of experts on the issue. Published in the British Dental Journal, the list was constructed in accordance with a modified version of the Delphi method, a systematic, multistage feedback survey.

The full list of never events is as follows:

Breaking the patient’s jaw
Pulling out the wrong tooth
Treating the wrong patient
Injecting the wrong anaesthetic
Injuring the patient’s eye, owing to omission of appropriate eye protection
Leaving foreign objects behind in the patient after surgical procedures
Inhalation by the patient of foreign objects
Failing to sterilise instruments
Failing to register the patient’s history of allergies to medication
Using a dental material in a patient with a known history of allergy to the dental material
Prescribing a drug to a patient with a known allergy to the drug
Reusing disposable items instead of throwing them away
Failing to refer for oral cancer assessment after the patient’s lesions do not heal after two weeks of receiving treatment
Failing to implement oral cancer screening as part of routine assessment
Prescribing incorrect medication to children.

“Never events are a vital way to flag failures in procedure that put patient safety at risk,” said project leader Prof. Aziz Sheikh, Director of the University of Edinburgh’s Usher Institute of Population Health Sciences and Informatics. “By listing a consensus position on never events in dentistry, we hope that regulators and professional bodies will be able to assess the frequency of such events and reduce their occurrence.”

“Our definitive list of never events reflects a collaborative international effort to improve patient safety,” added Prof. Raman Bedi, emeritus professor at King’s College London and former Chief Dental Officer of England, who was involved in the study. “We hope the list will improve care for all patients by creating an environment of openness where all members of the dental team can easily report adverse incidents.”

The study, titled “Developing agreement on never events in primary care dentistry: An international eDelphi study”, was published online on 11 May 2018 in the British Dental Journal.

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