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)

Abstract

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.
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Bowie, Dr Paul
• Authors: Black, I., and Bowie, P.
• College/School: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > General Practice and Primary Care
• Journal Name: British Dental Journal
• Publisher: Nature Publishing Group for the British Dental Association
• ISSN: 0007-0610
• 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