Focus on human factors behind incidents

News

  Posted by: The Probe      27th February 2020

Leo Briggs, deputy head of the DDU examines how we need to better understand human error when looking at improving patient safety.

Human error is inevitable in any walk of life. But in dentistry, where one slip has the potential to cause lasting harm to a patient, the stakes are higher. In an ideal world, every conscientious dental professional would have the time, space and support to treat patients. They would never be fatigued, under time pressure because of a full waiting room, their usual dental nurse would always be in attendance, equipment would operate perfectly and every patient would be calm personified.

Of course, the reality of clinical practice is far from perfect and factors like tiredness or poor team communication can contribute to human error. Sadly, when adverse incidents do occur, dental professionals may be individually blamed or face an investigation – when it would be better for everyone to find out what went wrong, and to learn from it.

The role of human factors is to examine why errors occur and then develop strategies to ‘absorb’ the risk by improving work systems, processes and technological innovation. In an interview in the DDU journal, Professor Simon Wright, chairman of the National Advisory Board for Human Factors in Dentistry explained: “The first thing we have to do is create a culture within dentistry where we all understand that we make errors and learn from them, rather than try to hide the fact we are making them because of the possible consequences.”

But how can we do this in practice? It takes a team effort as the following fictitious case shows.

A foundation dentist had been asked by the orthodontist treating a 14-year old girl to remove a retained lower right deciduous second molar (LRE). When the foundation dentist examined the patient, he incorrectly identified the lower right first permanent molar (LR6) as the tooth to be removed.

After administering local anaesthetic and checking for adequate analgesia, the dentist prepared to extract the tooth. Fortunately, the dental nurse was observing closely and as the dentist was about to begin the extraction the nurse intervened to point out the error.

The dentist paused the procedure, and identified the correct tooth by checking it in the mouth against the referral letter from the orthodontist, the dental charting and radiographs, and double-checked it with the patient, the accompanying parent, and the dental nurse. Having satisfied himself that the correct tooth had now been positively identified, the LRE was removed uneventfully.

The foundation dentist discussed this ‘near miss’ with his educational supervisor, and the nurse was praised for intervening and speaking up to avoid what would otherwise have been a serious adverse incident.

A root cause analysis was carried out and there was a discussion about the near miss at a practice meeting. One of the outcomes was that in the future the practice would adopt the Royal College of Surgeons dental LocSSIP tool aimed at preventing erroneous extractions.

You can see more about this issue in the latest issue of the DDU journal ddujournal.theddu.com


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