Patient safety in dentistry: development of a candidate 'never event' list for primary care

Black, I. and Bowie, P. (2017) Patient safety in dentistry: development of a candidate 'never event' list for primary care. British Dental Journal, 222(10), pp. 782-788. (doi:10.1038/sj.bdj.2017.456) (PMID:28546608)

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Introduction The 'never event' concept is often used in secondary care and refers to an agreed list of patient safety incidents that 'should not happen if the necessary preventative measures are in place'. Such an intervention may raise awareness of patient safety issues and inform team learning and system improvements in primary care dentistry. Objective To identify and develop a candidate never event list for primary care dentistry. Methods A literature review, eight workshops with dental practitioners and a modified Delphi with 'expert' groups were used to identify and agree candidate never events. Results Two-hundred and fifty dental practitioners suggested 507 never events, reduced to 27 distinct possibilities grouped across seven themes. Most frequently occurring themes were: 'checking medical history and prescribing' (119, 23.5%) and 'infection control and decontamination' (71, 14%). 'Experts' endorsed nine candidate never event statements with one graded as 'extreme risk' (failure to check past medical history) and four as 'high risk' (for example, extracting wrong tooth). Conclusion Consensus on a preliminary list of never events was developed. This is the first known attempt to develop this approach and an important step in determining its value to patient safety. Further work is necessary to develop the utility of this method.

Item Type:Articles
Additional Information:Study funding was provided by NHS Education for Scotland, Edinburgh, Scotland, UK.
Glasgow Author(s) Enlighten ID:Bowie, Dr Paul
Authors: Black, I., and Bowie, P.
College/School:College of Medical Veterinary and Life Sciences > Institute of Health and Wellbeing > General Practice and Primary Care
Journal Name:British Dental Journal
Publisher:Nature Publishing Group for the British Dental Association
ISSN (Online):1476-5373
Published Online:26 May 2017
Copyright Holders:Copyright © 2017 The Authors
First Published:First published in British Dental Journal 222(10): 782-788
Publisher Policy:Reproduced under a Creative Commons license

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