How Dental Team Members Describe Adverse Events

Dr. Elsbeth Kalenderian spoke with Dr. Chiraz Guessaier about an article she recently co-authored and published in the Journal of the American Dental Association: “How Dental Team Members Describe Adverse Events.”

Much information is available in medicine about patient safety and data related to safety; however, it is lacking in dentistry.

The researchers obtained this information through the creation of an “adverse event inventory” by interviewing providers and team members and asking what incidents might occur in the dental setting. The researchers divided interviewees into 2 groups – domain experts (specialists) and focus groups (academics, staff, students and residents). The entire session was akin to a brainstorming session and the questions they were asked included:

1. What are the most common adverse effects that you see in practice?
2. What are some of the least common adverse effects that you see in practice?
3. Which events should never happen (a never event)?
4. Are there other events that come to mind outside of your area of expertise?
5. Are there any others that come to mind (brainstorm)?

Findings

• There is confusion between what is a cause and what is an adverse event (e.g. An open margin is not an adverse event, but it can lead to secondary caries which could be an adverse event)
• The research produced a list of 747 unique adverse events and 540 unique causes that could lead to an adverse event

Implications

All dental team members should realize that major “never” events occur rarely in dental offices, however adverse events do occur, even if not often. It is important to understand that all members of the team need to be proactive. System issues need to be resolved that will help prevent adverse events in the future and that will improve overall patient safety.