Several initiatives aimed at improving the quality of care throughout the UK have been proposed and implemented over the last few years. In response to growing concerns over the number of adverse incidents affecting patients across a wide range of medical practices, patient advocacy groups in tandem with the NHS have placed more attention on developing workable methods for healthcare providers and their staff. The common goal remains: protecting the patient population from errors or oversight due to miscommunication, poor judgment, or a shortfall in training while providing a greater sense of transparency and efficiency within the medical community.
The National Patient Safety Agency, or NPSA, began identifying specific adverse events that had the potential to harm patients in a significant way. Never events, defined by the NPSA and the NHS as serious, largely preventable patient safety incidents that cause significant harm, were first published in 2009 as a way to educate providers on the power of taken preventative steps to ensure the safety of patients undergoing major medical procedures, like surgery. In addition to identifying never events, the organisation also created a reporting requirement for providers, making it mandatory to share details of any situation where a never event occurred. While beneficial in theory, many providers needed clarity surrounding the prevention and potential reporting of never events in practice.
Murky Water for Dental Surgeons
One of the more confusing aspects of the list of never events identified by NPSA applied to dental hospitals and the lack of understanding if tooth extractions were considered surgery under the never event definition. Although wrong tooth extractions are widely avoidable, they make up a significant portion of wrong site surgical errors reported by the patient population. Because the never events listed out did not explicitly include the common surgery as a reportable event when the wrong tooth was removed, there remained questions as to whether or not a wrong tooth extraction was considered severe enough to report to the powers that be.
In the last few years, updates to the never event definition have cleared the murky waters for dental hospitals and their staff, expanding the definition of surgical procedures. A representative from a leading medical solicitor firm in the UK explained that wrong tooth extractions now fall into the never events framework published by the NHS. The updated information states that a never event is a surgical intervention performed on the wrong person or the wrong site, including a wrong tooth. This updated definition of never events in surgery settings provides a clearer path for dental hospitals and providers toward understanding what constitutes reportable never events, and which procedures require extra care to avoid a never event from taking place.
Promising Research
Shortly after the first guidelines on never events were published, patient advocacy groups came together to establish a plan for improving the quality of care and the avoidance of never events in all medical settings. To this end, an urgent recommendation to utilise a patient safety checklist prior to surgery was pushed to NHS trusts. In the years following the recommendation, all NHS organisations implement a safer surgery checklist on patients undergoing a major procedure in an effort to reduce adverse events from taking place. A recent survey conducted throughout England and Ireland found the same to be true of dental hospitals, specifically focused on wrong tooth extraction.