Abstract:

Adverse events pose a serious problem for quality of healthcare. Dental practice is eminently invasive and involves close and routine contact with secretions; as such, it is potentially prone to the occurrence of adverse events. Various patient safety studies have been developed in the last two decades, but mostly in the hospital setting due to the organizational complexity, severity of the cases, and diversity and specificity of the procedures. The objective was to identify and explore studies on patient safety in Dentistry. An integrative literature review was performed in MEDLINE via PubMed, Scopus via Portal Capes, and the Regional Portal of the Virtual Health Library, using the terms patient safety and dentistry in English, Spanish, and Portuguese, starting in 2000. The research cycle in patient safety was used, as proposed by the World Health Organization to classify studies. We analyzed 91 articles. The most common adverse events were allergies, infections, diagnostic delay or failure, and technical error. Measures to mitigate the problem highlight the need to improve communications, encourage reporting, and search for tools to assist the management of care. The authors found a lack of studies on implementation and assessment of the impact of proposals for improvement. Dentistry has made progress in patient safety but still needs to transpose the results into practice, where efforts are crucial to prevent adverse events.

Keywords:
Patient Safety; Dentistry; Quality of Health Care; Adverse Event

Introduction

The World Health Organization (WHO) defines patient safety as “the reduction of risk of unnecessary harms related to healthcare to an acceptable minimum” ¹1. Organização Mundial da Saúde. Estrutura conceitual da Classificação Internacional sobre Segurança do Doente. Relatório técnico final. Lisboa: Organização Mundial da Saúde; 2011. (p. 21). The focus is on the prevention of adverse events (AE), defined as harms to the patient resulting from the care rather than the underlying disease ¹1. Organização Mundial da Saúde. Estrutura conceitual da Classificação Internacional sobre Segurança do Doente. Relatório técnico final. Lisboa: Organização Mundial da Saúde; 2011..

The theme of patient safety and quality of care has been with us for some time ²2. Trindade L, Lage MJW. A perspectiva histórica e principais desenvolvimentos da segurança do paciente. In: Sousa P, Mendes W, organizadores. Segurança do paciente: conhecendo os riscos nas organizações de saúde. 2a Ed. Rio de Janeiro: Coordenação de Desenvolvimento EducacionaI e EAD, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2019. p. 41-58.. However, it was not until the publications To Err is Human: Building a Safer Health System³3. Institute of Medicine Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington DC: National Academies Press; 2000. and Crossing the Quality Chasm: A New Health System for the 21st Century⁴4. Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academies Press; 2001. by the U.S. Institute of Medicine that the problem’s magnitude and its clinical, economic, and social dimensions were exposed more clearly, underscoring the gap between the promised quality and the quality actually delivered.

Since then, under the leadership of international organizations, especially the WHO, patient safety has gained its own body of scientific knowledge ⁵5. World Health Organization. Assessing and tackling patient harm: a methodological guide for data-poor hospitals. Geneva: World Health Organization; 2010.. Studies have grown and are proving essential for: (i) producing knowledge in the area; (ii) disseminating information; (iii) supporting decisions; (iv) promoting evidence-based practices; and (v) monitoring and assessing the impact of measures aimed at increasing patient safety and improving the quality of patient care ⁶6. Caldas BN, Sousa P, Mendes W. Investigação/pesquisa em segurança do paciente. In: Sousa P, Mendes W, organizadores. Segurança do paciente: criando organizações de saúde seguras. 2ª Ed. Rio de Janeiro: Coordenação de Desenvolvimento EducacionaI e EAD, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2019. p. 201-23..

Most of the studies have been conducted in the hospital setting, probably due to its organizational complexity, severity of the cases, diversity, and specificity of procedures ⁷7. Mendes W, Martins M, Rozenfeld S, Travassos C. The assessment of adverse events in hospitals in Brazil. Int J Qual Health Care 2009; 21:279-84.. Although dentists’ work is mostly in the outpatient setting, the provision of dental care is prone to the occurrence of AE. Dental practice is eminently invasive, involves close and routine contact with secretions such as saliva and blood ⁸8. Hughes A, Davies L, Hale R, Gallagher JE. Adverse incidents resulting in exposure to body fluids at a UK dental teaching hospital over a 6-year period. Infect Drug Resist 2012; 5:155-61.; depends on the professional’s skill, and entails constant exposure to possible medical emergencies ⁹9. Yamalik N, Perea-Pérez B. Patient safety and dentistry: what do we need to know? Fundamentals of patient safety, the safety culture and implementation of patient safety measures in dental practice. Int Dent J 2012; 62:189-96.^,1010. Bailey E, Tickle M, Campbell S. Patient safety in primary care dentistry: where are we now? Br Dent J 2014; 217:339-44..

Meanwhile, major technological progress in recent decades led to greater ease and precision in diagnoses and treatments ¹¹11. Viola NV, Oliveira ACM, Dota EAV. Ferramentas automatizadas: o reflexo da evolução tecnológica na Odontologia. Rev Bras Odontol 2011; 68:76-80., while adding greater complexity to the care and thus increasing the risk of dental AE ¹²12. Thusu S, Panesar S, Bedi R. Patient safety in dentistry - state of play as revealed by a national database of errors. Br Dent J 2012; 213:E3..

Given this scenario, the article aimed to identify and explore studies focused on patient safety in Dentistry. It is essential to explore the contents of these publications to highlight possible contributions to practice and identify potential points of departure for continuity, indispensable for understanding the problem and seeking improvements in quality of care and patient safety in this context.

Method

This was an integrative literature review oriented by the following question: “What research developments have occurred in the field of patient safety in Dentistry, and what contributions have the studies made to the safety of care?”. To answer this question, we conducted searches in the databases MEDLINE via PubMed, VHL Regional, and Scopus via Portal Capes, since these contain most of the publications in the health field. We used the terms from the MeSH terms (Medical Subject Heading; https://www.ncbi.nlm.nih.gov/mesh/) in English: patient safety and dentistry in the title and/or abstract (Box 1).

The inclusion criteria were: scientific articles in English, Spanish, or Portuguese, by authors’ convenience, and representing the great majority of publications in this area; that prioritized patient safety in Dentistry, that included quantitative, qualitative, evaluative, intervention, reflection, document analysis, and literature review methodologies; published since January 1, 2000 - the year of publication of the report To Err is Human: Building a Safer Health System - until June 30, 2019.

Exclusion criteria were articles that did not address patient safety as the central approach, such as: those focusing mainly on legal aspects, workers’ health, and biosafety; articles involving other health professions; editorials, letters, recommendations by agencies/institutions, opinions/commentary, and interviews; duplicate articles; those without abstracts; and non-accessible publications. The titles and abstracts were read by two independent reviewers, and doubts were resolved by consensus between the two.

The included studies were categorized by year, country of publication, method, and main objective. The latter categorization, conducted by the authors, was based on an approach to the components in the research cycle proposed by the WHO ⁶6. Caldas BN, Sousa P, Mendes W. Investigação/pesquisa em segurança do paciente. In: Sousa P, Mendes W, organizadores. Segurança do paciente: criando organizações de saúde seguras. 2ª Ed. Rio de Janeiro: Coordenação de Desenvolvimento EducacionaI e EAD, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2019. p. 201-23. (Box 2); descriptive studies that analyzed and discussed patient safety concepts and their application to Dentistry but which did not allow fitting them into the research cycle’s components were classified as “others”.

Results

The search in the three databases identified 315 articles: 95 captured by MEDLINE, 21 via VHL Regional, and 199 through Scopus. After excluding 99 articles, 86 duplicates, 7 without an available abstract, and 6 unavailable, 216 articles were selected for reading the title and abstract. Based on the references found, 9 more articles were captured and added to the sample (Figure 1).

The final sample consisted of 91 articles. Countries with the most publications were United States (39.3%; n = 33) and England (31%; n = 28); Brazil, Canada, China, Chile, Scotland, Netherlands, Mexico, Pakistan, Sweden, and Switzerland presented only 1 publication each during the period (Table 1).

Based on the included studies’ objectives, categorized by the components of the research cycle proposed by the WHO ⁶6. Caldas BN, Sousa P, Mendes W. Investigação/pesquisa em segurança do paciente. In: Sousa P, Mendes W, organizadores. Segurança do paciente: criando organizações de saúde seguras. 2ª Ed. Rio de Janeiro: Coordenação de Desenvolvimento EducacionaI e EAD, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2019. p. 201-23., we found that some studies addressed more than one component. Most were focused on the initial phases: measuring the harm (28.6%; n = 26); understanding the causes (56%; n = 51); and identifying solutions (32%; n = 30). Eight studies (11%) aimed to assess the impact, and two studies (2.2%) aimed to transpose the evidence into safer care (Box 3).

Of the 91 studies, 47.3% (n = 43) used quantitative methods, especially cross-sectional designs and retrospective patient chart reviews. Only 8.8% (n = 8) used qualitative designs (Box 3).

Discussion

Focus on patient safety in Dentistry

Publications on patient safety in Dentistry have grown worldwide, although with just minor increases; England and the United States accounted for most of the included studies. A strong primary healthcare (PHC) system, as in England, and pioneering work in institutions dedicated to healthcare quality improvement, as in the United States, may help explain these findings.

The area’s specificities may point to reasons for the low number of studies: (i) procedures that are generally less invasive than those of medical surgery and are thus less prone to serious harms; (ii) dental complications are often treated in hospital emergency departments, and the initial attending dentist may thus not learn of the incident; (iii) a large share of the care takes places in the private sector and/or in individual dentists’ offices, and fear of losing patients may limit reporting of the harm; and (iv) less familiarity with the issue in private practices than in the hospital setting, which is historically more amenable to campaigns, courses, and greater control of AE ⁹9. Yamalik N, Perea-Pérez B. Patient safety and dentistry: what do we need to know? Fundamentals of patient safety, the safety culture and implementation of patient safety measures in dental practice. Int Dent J 2012; 62:189-96.^,1313. Perea-Pérez B, Santiago-Sáez A, García-Marín F, Labajo-González E, Villa-Vigil A. Patient safety in dentistry: dental care risk management plan. Med Oral Patol Oral Cir Bucal 2011; 16:e805-9..

However, while some characteristics may explain the lack of contact with patient safety issues, other characteristics raise challenges for professional dental practice that should encourage more studies. We highlight the predominance of surgical procedures and their complications, such as bleeding and infections, constant exposure to ionizing radiation, and the need to be alert to the patient’s health history ¹⁰10. Bailey E, Tickle M, Campbell S. Patient safety in primary care dentistry: where are we now? Br Dent J 2014; 217:339-44..

We observed a similar trend in studies in patient safety in Dentistry to those of patient safety in general ¹⁴14. Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med 2003; 18:61-7.^,1515. Murff HJ, Patel VL, Hripcsak G, Bates DW. Detecting adverse events for patient safety research: a review of current methodologies. J Biomed Inform 2003; 36:131-43. in relation to the sources and techniques adopted. The initial studies, which were exploratory, sought to draw a parallel between dentistry and patient safety ⁹9. Yamalik N, Perea-Pérez B. Patient safety and dentistry: what do we need to know? Fundamentals of patient safety, the safety culture and implementation of patient safety measures in dental practice. Int Dent J 2012; 62:189-96.^,1010. Bailey E, Tickle M, Campbell S. Patient safety in primary care dentistry: where are we now? Br Dent J 2014; 217:339-44.^,1616. Perea-Pérez B. Seguridad del paciente y odontología. Cient Dent 2010; 8:9-15.^,1717. Speers RD, McCulloch CA. Optimizing patient safety: can we learn from the airline industry? J Can Dent Assoc 2014; 80:e37.^,1818. O'Brien T. Reducing harm in healthcare systems. Prim Dent J 2015; 4:34-7.^,1919. Bagg J, Welbury R. The Francis Report: why it matters to the dental team. Dent Update 2015; 42:206-9.^,2020. Castillo HPC. Seguridad del paciente en los servicios de estomatología. Rev ADM 2016; 73:155-62.. These then gave way to more specific approaches ²¹21. Piccinni C, Gissi DB, Gabusi A, Montebugnoli L, Poluzzi E. Paraesthesia after local anaesthetics: an analysis of reports to the FDA Adverse Event Reporting System. Basic Clin Pharmacol Toxicol 2015; 117:52-6.^,2222. Parker W, Estrich CG, Abt E, Carrasco-Labra A, Waugh JB, Conway A, et al. Benefits and harms of capnography during procedures involving moderate sedation: a rapid review and meta-analysis. J Am Dent Assoc 2018; 149:38-50.e2., suggesting greater participation by Dentistry in the multidisciplinary approach that the patient safety theme requires.

The problem’s size and understanding its causes

While the first studies in patient safety aimed to measure the incidence or prevalence of AE to know the problem’s magnitude ⁶6. Caldas BN, Sousa P, Mendes W. Investigação/pesquisa em segurança do paciente. In: Sousa P, Mendes W, organizadores. Segurança do paciente: criando organizações de saúde seguras. 2ª Ed. Rio de Janeiro: Coordenação de Desenvolvimento EducacionaI e EAD, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2019. p. 201-23., the initial studies in Dentistry, besides measuring their frequency, aimed to understand their causes, sparking reflection on the inherent challenges in the specificities of dental practice.

From the perspective of measuring the incidence/prevalence of harms, the studies ¹²12. Thusu S, Panesar S, Bedi R. Patient safety in dentistry - state of play as revealed by a national database of errors. Br Dent J 2012; 213:E3.^,2121. Piccinni C, Gissi DB, Gabusi A, Montebugnoli L, Poluzzi E. Paraesthesia after local anaesthetics: an analysis of reports to the FDA Adverse Event Reporting System. Basic Clin Pharmacol Toxicol 2015; 117:52-6.^,2323. Kalenderian E, Walji MF, Tavares A, Ramoni RB. An adverse event trigger tool in dentistry: a new methodology for measuring harm in the dental office. J Am Dent Assoc 2013; 144:808-14.^,2424. Mettes T, Bruers J, van der Sanden W, Wensing M. Patient safety in dental care: a challenging quality issue? An exploratory cohort study. Acta Odontol Scand 2013; 71:1588-93.^,2525. Hiivala N, Mussalo-Rauhamaa H, Murtomaa H. Patient safety incidents reported by Finnish dentists: results from an internet-based survey. Acta Odontol Scand 2013; 71:1370-7.^,2626. Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth 2013; 23:741-6.^,2727. Perea-Pérez B, Labajo-González E, Santiago-Sáez A, Albarrán-Juan E, Villa-Vigil A. Analysis of 415 adverse events in dental practice in Spain from 2000 to 2010. Med Oral Patol Oral Cir Bucal 2014; 19:500-5.^,2828. Jonsson L, Gabre P. Adverse events in public dental service in a Swedish county: a survey of reported cases over two years. Swed Dent J 2014; 38:151-60.^,2929. Akifuddin S, Khatoon F. Reduction of complications of local anaesthesia in dental healthcare setups by application of the sixsigma methodology: a statistical quality improvement technique. J Clin Diagn Res 2015; 9:ZC34-8.^,3030. Christiani JJ, Rocha MT, Valsecia M. Seguridad del paciente en la práctica odontológica. Acta Odontol Colomb 2015; 5:21-32.^,3131. Obadan EM, Ramoni RB, Kalenderian E. Lessons learned from dental patient safety case reposts. J Am Dent Assoc 2015; 146:318-26.^,3232. Hebballi NB, Ramoni R, Kalenderian E, Delattre VF, Stewart DC, Kent K, et al. The dangers of dental devices as reported in the Food and Drug Administration Manufacturer and User Facility Device Experience Database. J Am Dent Assoc 2015; 146:102-10.^,3333. Hiivala N, Mussalo-Rauhamaa H, Tefke HL, Murtomaa H. An analysis of dental patient safety incidents in a patient complaint and healthcare supervisory database in Finland. Acta Odontol Scand 2016; 74:81-9.^,3434. Maramaldi P, Walji MF, White J, Etolue J, Kahn M, Vaderhobli R, Kwatra J, et al. How dental team members describe adverse events. J Am Dent Assoc 2016; 147:803-11.^,3535. Ensaldo-Carrasco E, Suarez-Ortegon MF, Carson-Stevens A, Cresswell K, Bedi R, Sheikh A. Patient safety incidents and adverse events in ambulatory dental care: a systematic scoping review. J Patient Saf 2016; (Online ahead of print).^,3636. Tokede O, Walji M, Ramoni R, Rindal DB, Worley D, Hebballi N, et al. Quantifying dental office-originating adverse events: the Dental Practice Study methods. J Patient Saf 2017; (Online ahead of print).^,3737. Corrêa CDTSO, Mendes W. Proposal of a trigger tool to assess adverse events in dental care. Cad Saúde Pública 2017; 33:e00053217.^,3838. Osegueda-Espinosa AA, Sánchez-Pérez L, Perea-Pérez B, Labajo-González E, Acosta-Gio AE. Dentists survey on adverse events during their clinical training. J Patient Saf 2017; (Online ahead of print).^,3939. Huertas MF, Gonzalez J, Camacho S, Sarralde AL, Rodríguez A. Analysis of the adverse events reported to the office of the clinical director at a dental school in Bogotá, Colombia. Acta Odontol Latinoam 2017; 30:19-25.^,4040. Pesántez Alvarado JM, Camacho Ladino JM, Rodríguez Ciódaro A, Camacho Peña SP, Sarralde Delgado AL, Castro Haiek DE, et al. Análisis de los eventos desfavorables como resultado de la atención en cirugía oral. Univ Odontol 2017; 36(77). https://revistas.javeriana.edu.co/index.php/revUnivOdontologica/article/view/21137.
https://revistas.javeriana.edu.co/index.... ^,4141. Pérez Gómez W, Pita Bejarano AM, Ramos Vargas CA, González Moncada J, Güiza Cristancho EH, Rodríguez Ciódaro A. Análisis de los eventos adversos em el área de rehabilitación oral de la Facultad de Odontología de la Pontificia Universidad Javeriana Bogotá. Univ Odontol 2017; 36(77). https://revistas.javeriana.edu.co/index.php/revUnivOdontologica/article/view/20829.
https://revistas.javeriana.edu.co/index.... ^,4242. Kalenderian E, Obadan-Udoh E, Yansane A, Kent K, Hebballi NB, Delattre V, et al. Feasibility of electronic health record-based triggers in detecting dental adverse events. Appl Clin Inform 2018; 9:646-53.^,4343. Stahl JM, Mack K, Cebula S, Gillingham BL. Dental patient safety in the military health system: joining medicine in the journey to high reliability. Mil Med 2019; 185:e262-8. produced findings that ranges from the complications of local anesthesia/sedation; lesions to the tongue and lips; and loss of teeth from switched tooth extractions, ocular lesions and even death. Incidents involved allergies, infections, diagnostic delay or failure, and failure in the procedure, among others. However, as addressed appropriately by Ensaldo-Carrasco et al. ³⁵35. Ensaldo-Carrasco E, Suarez-Ortegon MF, Carson-Stevens A, Cresswell K, Bedi R, Sheikh A. Patient safety incidents and adverse events in ambulatory dental care: a systematic scoping review. J Patient Saf 2016; (Online ahead of print)., the evidence is still considered insufficient to provide reliable estimates on the incidence and frequency of these events.

In the effort to characterize “never events” in dentistry, defined as incidents that resulted in death or significant disability for the patient and that should never occur ⁴⁴44. Renton T, Sabbah W. Review of never and serious events related to dentistry 2005-2014. Br Dent J 2016; 221:71-9., three studies used a qualitative methodology and produced distinct classifications ⁴⁴44. Renton T, Sabbah W. Review of never and serious events related to dentistry 2005-2014. Br Dent J 2016; 221:71-9.^,4545. Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care. Br Dent J 2017; 222:782-8.^,4646. Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, Bedi R, Sheikh A. Developing agreement on never events in primary care dentistry: an international eDelphi study. Br Dent J 2018; 224:733-40.. Renton & Sabbah ⁴⁴44. Renton T, Sabbah W. Review of never and serious events related to dentistry 2005-2014. Br Dent J 2016; 221:71-9. used a list of never events from the English National Health Service (NHS) updated in 2015/2016. Black & Bowie ⁴⁵45. Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care. Br Dent J 2017; 222:782-8. refined 507 suggestions from 250 dentists using the modified Delphi method. Ensaldo-Carrasco et al. ⁴⁶46. Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, Bedi R, Sheikh A. Developing agreement on never events in primary care dentistry: an international eDelphi study. Br Dent J 2018; 224:733-40. also used the modified Delphi method, but drew on the literature to create an initial list of never events that was then refined by 41 specialists from various countries.

To study the avoidability of AE, Pérez Gómez et al. ⁴¹41. Pérez Gómez W, Pita Bejarano AM, Ramos Vargas CA, González Moncada J, Güiza Cristancho EH, Rodríguez Ciódaro A. Análisis de los eventos adversos em el área de rehabilitación oral de la Facultad de Odontología de la Pontificia Universidad Javeriana Bogotá. Univ Odontol 2017; 36(77). https://revistas.javeriana.edu.co/index.php/revUnivOdontologica/article/view/20829.
https://revistas.javeriana.edu.co/index.... analyzed 595 patient charts and found 36 AE. Of these, 21 (58%) were considered avoidable. Mettes et al. ²⁴24. Mettes T, Bruers J, van der Sanden W, Wensing M. Patient safety in dental care: a challenging quality issue? An exploratory cohort study. Acta Odontol Scand 2013; 71:1588-93. identified a total of 46 dental AE, 39% of which were considered avoidable. The authors inferred that although the relatively low percentage of avoidable AE suggested safety in dental practice, the records’ low quality plus the subjectivity of the avoidability concept may imply the measure’s underestimation. The situation calls for a critical analysis, especially when comparing the above-mentioned studies with two others: Huertas et al. ³⁹39. Huertas MF, Gonzalez J, Camacho S, Sarralde AL, Rodríguez A. Analysis of the adverse events reported to the office of the clinical director at a dental school in Bogotá, Colombia. Acta Odontol Latinoam 2017; 30:19-25. in which 43 of the 227 complaints analyzed were classified as AE, 42 (98%) avoidable, and Pesántez Alvarado et al. ⁴⁰40. Pesántez Alvarado JM, Camacho Ladino JM, Rodríguez Ciódaro A, Camacho Peña SP, Sarralde Delgado AL, Castro Haiek DE, et al. Análisis de los eventos desfavorables como resultado de la atención en cirugía oral. Univ Odontol 2017; 36(77). https://revistas.javeriana.edu.co/index.php/revUnivOdontologica/article/view/21137.
https://revistas.javeriana.edu.co/index.... , analyzing 1,062 clinical histories of patients that underwent surgical procedures and identifying 11 AE, 9 of which (82%) were classified as avoidable.

The contributing factors to unsafe care featured diagnostic and/or planning errors, ineffective communication, failure in the performance of procedures, low adherence to protocol, and insufficient history-taking ²⁵25. Hiivala N, Mussalo-Rauhamaa H, Murtomaa H. Patient safety incidents reported by Finnish dentists: results from an internet-based survey. Acta Odontol Scand 2013; 71:1370-7.^,3333. Hiivala N, Mussalo-Rauhamaa H, Tefke HL, Murtomaa H. An analysis of dental patient safety incidents in a patient complaint and healthcare supervisory database in Finland. Acta Odontol Scand 2016; 74:81-9.^,3939. Huertas MF, Gonzalez J, Camacho S, Sarralde AL, Rodríguez A. Analysis of the adverse events reported to the office of the clinical director at a dental school in Bogotá, Colombia. Acta Odontol Latinoam 2017; 30:19-25.^,4343. Stahl JM, Mack K, Cebula S, Gillingham BL. Dental patient safety in the military health system: joining medicine in the journey to high reliability. Mil Med 2019; 185:e262-8.^,4747. Christiani JJ, Rocha MT. Percepción de la seguridad del paciente en odontología. Rev Asoc Odontol Argent 2015; 103:154-9.^,4848. Bailey E. Contemporary views of dental practitioners' on patient safety. Br Dent J 2015; 219:535-40.. These factors were described in turn as either latent or active. Obadan et al. ³¹31. Obadan EM, Ramoni RB, Kalenderian E. Lessons learned from dental patient safety case reposts. J Am Dent Assoc 2015; 146:318-26. analyzed hypothetically the accidental ingestion of foreign bodies and pointed to low clinical capacity, inadequate training, and deficient equipment maintenance as possible latent failures and inadequate protection of the patient’s airways as an active failure.

AE resulting from medication include prescription, dispensing, and administration and are widely described in the scientific literature. In the context of PHC, drug prescription was reported as one of the principal causes of AE ⁴⁹49. Marchon SG, Mendes WV. Segurança do paciente na atenção primária à saúde: revisão sistemática. Cad Saúde Pública 2014; 30:1815-35., corroborating the object of one of the first studies included: drug prescription in Dentistry ⁵⁰50. Mendonça JMD, Lyra Jr. DP, Rabelo JS, Siqueira JS, Balisa-Rocha BJ, Gimenes FRE, et al. Analysis and detection of dental prescribing errors at primary health care units in Brazil. Pharm World Sci 2010; 32:30-5..

Studies have demonstrated the need to focus attention on the use of medicines and other substances. The sugar in many pharmaceuticals can act as a cofactor for caries, particularly in patients with difficulty swallowing ⁵¹51. Donaldson M, Goodchild JH, Epstein JB. Sugar content, cariogenicity, and dental concerns with commonly used medications. J Am Dent Assoc 2015; 146:129-33.. Weight-loss drugs ⁵²52. Donaldson M, Goodchild JH, Ziegler J. Dental considerations for patients taking weight-loss medications. J Am Dent Assoc 2014; 145:70-4., dietary supplements ⁵³53. Donaldson M, Touger-Decker R. Dietary supplement interactions with medications used commonly in dentistry. J Am Dent Assoc 2013; 144:787-94., and vitamin supplements ⁵⁴54. Donaldson M, Touger-Decker R. Vitamin and mineral supplements: friend or foe when combined with medications? J Am Dent Assoc 2014; 145:1153-8. were also emphasized, suggesting that dentists should take these conditions into account in order to elaborate a safe, patient-centered treatment proposal.

Another concern is the association between AE and the technologies employed in dental care ⁵⁵55. Gluskin AH, Ruddle CJ, Zinman EJ. Thermal injury through intraradicular heat transfer using ultrasonic devices: precautions and practical preventive strategies. J Am Dent Assoc 2005; 136:1286-93.^,5656. Martín-Cameán A, Jos A, Mellado-García P, Iglesias-Linares A, Solano E, Cameán AM. In vitro and in vivo evidence of the cytotoxic and genotoxic effects of metal ions released by orthodontic appliances: a review. Environ Toxicol Pharmacol 2015; 40:86-113.. Along this line, Hebballi et al. ³²32. Hebballi NB, Ramoni R, Kalenderian E, Delattre VF, Stewart DC, Kent K, et al. The dangers of dental devices as reported in the Food and Drug Administration Manufacturer and User Facility Device Experience Database. J Am Dent Assoc 2015; 146:102-10. analyzed the reports of incidents with health devices notified to the U.S. Food and Drug Administration (FDA) in 2011. The results showed that out of a total of 1,978,056 reports, 28,046 (1.4%) were associated with dental devices. Some of the reports (2,942) were excluded because they did not furnish adequate information. Of the reports analyzed, 17,261 were related to injuries, 7,777 to poor functioning of the device, and 66 to deaths. Of these, 52 were clearly associated with the dental device.

Importantly, contributing factors are not associated only with the patient, but also with the healthcare providers and the work environment. Factors associated with patient characteristics include motor and/or intellectual disabilities and characteristics of children and the elderly. Factors associated with work conditions and the healthcare professional include agitated settings that favor distractions, high patient turnover, lack of skills from training, and deficient visibility and communication ⁵⁷57. Perea-Pérez B, Labajo-González E, Bratos-Murillo M, Santiago-Sáez A, Albarrán-Juan E, Villa-Vigil A. The clinical safety of disabled patients: proposal for a methodology for analysis of health care risks and specific measures for improvement. Med Oral Patol Oral Cir Bucal 2013; 18:e251-6..

Training is essential for dealing with the problems that professionals may face during their careers ⁵⁸58. Tan GM. A medical crisis management simulation activity for pediatric dental residents and assistants. J Dent Educ 2011; 75:782-90.^,5959. Raja S, Rajagopalan CF, Patel J, Van Kanegan K. Teaching dental students about patient communication following an adverse event: a pilot educational module. J Dent Educ 2014; 78:757-62.^,6060. Palmer JC, Blanchard JR, Jones J, Bailey E. Attitudes of dental undergraduate students towards patient safety in a UK dental school. Eur J Dent Educ 2019; 23:127-34., and it is important to incorporate the theme of patient safety starting in the early years of undergraduate school ⁶¹61. Al-Surimi K, Al Ayadi H, Salam M. Female dental students' perceptions of patient safety culture: a cross sectional study at a middle eastern setting. BMC Med Educ 2018; 18:301.. One study ³⁹39. Huertas MF, Gonzalez J, Camacho S, Sarralde AL, Rodríguez A. Analysis of the adverse events reported to the office of the clinical director at a dental school in Bogotá, Colombia. Acta Odontol Latinoam 2017; 30:19-25. of Dentistry students identified predisposing human factors related to AE such as operator fatigue, unawareness of risks, and failures of referrals. Corroborating these findings, Osegueda-Espinosa et al. ³⁸38. Osegueda-Espinosa AA, Sánchez-Pérez L, Perea-Pérez B, Labajo-González E, Acosta-Gio AE. Dentists survey on adverse events during their clinical training. J Patient Saf 2017; (Online ahead of print). called attention to the need for more active supervision in academic settings.

The studies confirm the importance of dentists’ training to prepare them to identify urgencies and situations that escape their control in order to proceed to adequate referrals, as emphasized by Al Blaihed et al. ⁶²62. Al Blaihed RM, Al Saeed MI, Abuabat AA, Ahsan SH. Incident reporting in dentistry: clinical supervisor's awareness, practice and perceived barriers. Eur J Dent Educ 2018; 22:e408-18., who described difficulties by professors in reporting incidents committed by students. They found that although there were verbal reports, the incidents were not recorded in writing, suggesting a weak local safety culture.

Patient safety culture means the beliefs, values, and standards shared by professionals and that also influence their behaviors and actions ⁶³63. Reis CT. Cultura de segurança em organizações de saúde. In: Sousa P, Mendes W, organizadores. Segurança do paciente: criando organizações de saúde seguras. 2ª Ed. Rio de Janeiro: Coordenação de Desenvolvimento EducacionaI e EAD, Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2019. p. 77-109.. In the course of this review, studies alluded to the theme ¹³13. Perea-Pérez B, Santiago-Sáez A, García-Marín F, Labajo-González E, Villa-Vigil A. Patient safety in dentistry: dental care risk management plan. Med Oral Patol Oral Cir Bucal 2011; 16:e805-9.^,6464. Pemberton MN, Ashley MP, Shaw A, Dickson S, Saksena A. Measuring patient safety in a UK dental hospital: development of a dental clinical effectiveness dashboard. Br Dent J 2014; 217:375-8.^,6565. Nelson TM, Xu Z. Pediatric dental sedation: challenges and opportunities. Clin Cosmet Investig Dent 2015; 7:97-106. or used it as their central focus ⁴⁷47. Christiani JJ, Rocha MT. Percepción de la seguridad del paciente en odontología. Rev Asoc Odontol Argent 2015; 103:154-9.^,6161. Al-Surimi K, Al Ayadi H, Salam M. Female dental students' perceptions of patient safety culture: a cross sectional study at a middle eastern setting. BMC Med Educ 2018; 18:301.^,6666. Leong P, Afrow J, Weber HP, Howell H. Attitudes toward patient safety standards in U.S. dental schools: a pilot study. Dent Educ 2008; 72:431-7.^,6767. Yamalik N, Van Dijk W. Analysis of the attitudes and needs/demands of dental practitioners in the field of patient safety and risk management. Int Dent J 2013; 63:291-7.^,6868. Ramoni R, Walji MF, Tavares A, White J, Tokede O, Vaderhobli R, et al. Open wide: looking into the safety culture of dental school clinics. J Dent Educ 2014; 78:745-56.^,6969. Ali I, Singla A, Gupta R, Patthi B, Dhama K, Niraj LK, et al. Psychometric utility in determining dental organizational attribute: a cross sectional study in Ghaziabad, India. J Clin Diagn Res 2017; 11:ZC52-5.^,7070. Al Sweleh FS, Al Saedan AM, Al Dayel OA. Patient safety culture perceptions in the college of dentistry. Medicine (Baltimore) 2018; 97:e9570.^,7171. Chew BKS, Sim DZ, Pau A. Dentists' perceptions of the meaning and promotion patient safety: a qualitative study. Oral Health Dent Manag 2018; 17:1-5.^,7272. Cheng H-C, Yen AM, Lee Y-H. Factors affecting patient safety culture among dental healthcare workers: a nationwide cross-sectional survey. J Dent Sci 2019; 14:263-8.^,7373. Choi EM, Mun SJ, Chung WG, Noh HJ. Relationships between dental hygienists' work environment and patient safety culture. BMC Health Serv Res 2019; 19:299.. Positive points were found, such has a high overall perception of patient safety; patient-centered care; the pursuit of effective and equitable care; and the value assigned to teamwork. The weaknesses described were low reporting of incidents and shortage of training, insufficient patient follow-up, and lack of the leadership’s support for patient safety.

It is essential to also focus on organizational factors such as failures in the physical environment, scheduling and managing patients, lines of responsibility, and influence of policies ³⁵35. Ensaldo-Carrasco E, Suarez-Ortegon MF, Carson-Stevens A, Cresswell K, Bedi R, Sheikh A. Patient safety incidents and adverse events in ambulatory dental care: a systematic scoping review. J Patient Saf 2016; (Online ahead of print).. A study of dental hygiene technicians showed that their perception of patient safety is inversely proportional to the number of hours worked and the number of patients treated ⁷³73. Choi EM, Mun SJ, Chung WG, Noh HJ. Relationships between dental hygienists' work environment and patient safety culture. BMC Health Serv Res 2019; 19:299..

Evidence shows that professionals involved in AE can suffer emotions that affect their performance and their health, potentially leading to substance use and depression ⁷⁴74. Nainar SMH. Adverse events during dental care for children: implications for practitioner health and wellness. Pediatr Dent 2018; 40:323-6.. Support by the organization for the professional involved in AE, also called the “second victim”, is one of the key issues for safety of care. Non-punitive support in cases of safety incidents and AE, as well as simplification of reporting systems can help enhance this approach ⁷⁰70. Al Sweleh FS, Al Saedan AM, Al Dayel OA. Patient safety culture perceptions in the college of dentistry. Medicine (Baltimore) 2018; 97:e9570.^,7575. Renton T, Master S. The complexity of patient safety reporting systems in UK dentistry. Br Dent J 2016; 221:517-24.. To allow an in-depth understanding of the AE problem requires combining the professionals’ technical knowledge with their cognitive and behavior aspects ⁷⁶76. Renouard F, Amalberti R, Renouard E. Are "human factors" the primary cause of complications in the field of implant dentistry? Int J Oral Maxillofac Implants 2017; 32:e55-e61..

Finally, the implementation of policies and periodic monitoring of compliance with clinical practice guidelines and patient safety ⁷⁷77. Vila-Sierra LA, Salcedo-Salgado JD, Fernández-Roncallo YY, Narváez-Barandica MM. Grado de implementación del proceso de seguridad en el paciente en IPS odontológicas públicas y privadas en Santa Marta. Rev Gerenc Políticas Salud 2017; 16:116-25. are necessary. The unavailability of national laws and/or regulations on patient safety in dentistry suggests low social awareness of the problem ⁶⁷67. Yamalik N, Van Dijk W. Analysis of the attitudes and needs/demands of dental practitioners in the field of patient safety and risk management. Int Dent J 2013; 63:291-7..

The solutions identified and their contribution to improvement in clinical safety

Studies on safety in surgical procedures were highlighted, possibly due to their more invasive nature. One study ⁷⁸78. Knepil GJ, Harvey CT, Beech AN. Marking the skin for oral surgical procedures: improving the WHO checklist. Br J Oral Maxillofac Surg 2013; 51:413-5. discussed the process of marking the surgical site as an opportunity for communication between patients and professionals, allowing to reduce the odds of errors such as switched tooth extractions, which is a major concern ⁴⁴44. Renton T, Sabbah W. Review of never and serious events related to dentistry 2005-2014. Br Dent J 2016; 221:71-9.^,7979. Cullingham P, Saksena A, Pemberton MN. Patient safety: reducing the risk of wrong tooth extraction. Br Dent J 2017; 222:759-63..

Improvement in communication led to the development of a chart for display in the hospital setting, in which healthcare professionals recorded the unsafe events that occurred during routine dental care, and which contributed to periodic discussions of quality improvement by the team ⁶⁴64. Pemberton MN, Ashley MP, Shaw A, Dickson S, Saksena A. Measuring patient safety in a UK dental hospital: development of a dental clinical effectiveness dashboard. Br Dent J 2014; 217:375-8..

In order to improve safety in anesthesia, adequate monitoring and a highly trained team were identified as key factors ⁸⁰80. Bennett JD, Kramer KJ, Bosack RC. How safe is deep sedation or general anesthesia while providing dental care? J Am Dent Assoc 2015; 146:705-8.^,8181. Robert RC, Patel CM. Oral surgery patient safety concepts in anesthesia. Oral Maxillofac Surg Clin North Am 2018; 30:183-93.. In addition, a systematic review suggested the routine addition of capnography to standard monitoring of adults during moderate sedation ²²22. Parker W, Estrich CG, Abt E, Carrasco-Labra A, Waugh JB, Conway A, et al. Benefits and harms of capnography during procedures involving moderate sedation: a rapid review and meta-analysis. J Am Dent Assoc 2018; 149:38-50.e2..

Checklists were considered effective in the improvement of work processes, optimization of communication, and the reduction of stress levels in surgeries ⁷⁸78. Knepil GJ, Harvey CT, Beech AN. Marking the skin for oral surgical procedures: improving the WHO checklist. Br J Oral Maxillofac Surg 2013; 51:413-5.^,8181. Robert RC, Patel CM. Oral surgery patient safety concepts in anesthesia. Oral Maxillofac Surg Clin North Am 2018; 30:183-93.^,8282. Perea-Pérez B, Santiago-Sáez A, García-Marín F, Labajo González E. Proposal for a 'surgical checklist' for ambulatory oral surgery. Int J Oral Maxillofac Surg 2011; 40:949-54.^,8383. Bailey E, Tickle M, Campbell S, O'Malley L. Systematic review of patient safety interventions in dentistry. BMC Oral Health 2015; 15:152.^,8484. Schmitt CM, Buchbender M, Musazada S, Bergauer B, Neukam FW. Evaluation of staff satisfaction after implementation of a surgical safety checklist in the ambulatory of an oral and maxillofacial surgery department and its impact on patient safety. J Oral Maxillofac Surg 2018; 76:1616-39.^,8585. Wright S, Ucer TC, Crofts G. The adaption and implementation of the WHO surgical safety checklist for dental procedures. Br Dent J 2018; 225:727-9.^,8686. Christiani JJ, Rocha MT. Checklist quirúrgico en odontología: componente clave en la seguridad del paciente. Rev Asoc Odontol Argent 2019; 107:33-7.. They also proved useful in the support of cancer diagnosis ⁸⁷87. Beddis HP, Davies SJ, Budenberg A, Horner K, Pemberton MN. Temporomandibular disorders, trismus and malignancy: development of a checklist to improve patient safety. Br Dent J 2014; 217:351-5. and strengthening the safety culture ⁸⁸88. Nenad MW, Halupa C, Spolarich AE, Gurenlian JR. A dental radiography checklist as a tool for quality improvement. J Dent Hyg 2016; 90:386-93..

For endodontic treatment, in addition to a checklist ⁸⁹89. Díaz-Flores-García V, Perea-Pérez B, Labajo-González E, Santiago-Sáez A, Cisneros-Cabello R. Proposal of a "checklist" for endodontic treatment. J Clin Exp Dent 2014; 6:e104-9., a protocol was proposed to decrease the occurrence of incidents with ultrasound energy ⁵⁵55. Gluskin AH, Ruddle CJ, Zinman EJ. Thermal injury through intraradicular heat transfer using ultrasonic devices: precautions and practical preventive strategies. J Am Dent Assoc 2005; 136:1286-93. and the use of rubber dams ⁹⁰90. Madarati A, Abid S, Tamimi F, Ezzi A, Sammani A, Shaar MBAA, et al. Dental-dam for infection control and patient safety during clinical endodontic treatment: preferences of dental patients. Int J Environ Res Public Health 2018; 15:E2012.^,9191. Asmarz HY, Benfati CAM, Bolan M. Accidental ingestion of a dental irrigation needle: a case report. Eur Arch Paediatr Dent 2019; 20:123-6.. The latter is a device that isolates the dental element for the endodontic procedure and avoids incidents such as aspiration and/or swallowing of artifacts.

As solutions to prevent drug-related AE, Skaar & O’Connor ⁹²92. Skaar DD, O'Connor H. Using the Beers criteria to identify potentially inappropriate medication use byolder adult dental patients. J Am Dent Assoc 2017; 148:298-307. emphasized the need to increase dentists’ knowledge of the prescribed drugs and their interactions. Donaldson & Goodchild ⁹³93. Donaldson M, Goodchild JH. Pharmacological reversal agents in dental practice: keys to patient safety. Compend Contin Educ Dent 2016; 37:681-7. emphasized the importance of orientation for these professionals on the use of pharmacological antagonists to help mitigate drug-induced medical emergencies.

Meanwhile, Noguerado et al. ⁹⁴94. Noguerado M, Perea B, Labajo E, Santiago A, García F. Seguridad del paciente: prescripción de fármacos enodontología a mujeres embarazadas y en período de lactancia. Cient Dent 2011; 8:51-60. proposed a guide for drug prescription for pregnant and breastfeeding women, and Hussein et al. ⁹⁵95. Hussein RJ, Krohn R, Kaufmann-Kolle P, Willms G. Quality indicators for the use of systemic antibiotics in dentistry. Z Evid Fortbild Qual Gesundhwes 2017; 122:1-8. suggested a set of indicators to improve prescription quality. Importantly, many medication errors occur due to failures that could easily be avoided, including low adherence to protocols and filling out illegible prescriptions ⁹⁶96. Perea-Pérez B, Labajo-González E, Acosta-Gío AE, Yamalik N. Eleven basic procedures/practices for dental patient safety. J Patient Saf 2015; 16:36-40.. Clinical activities in a university should represent the gold standard for professional performance ⁹⁷97. Rivera-Mendoza F, Acevedo-Atala C, Perea-Pérez B, Labajo-González E, Fonseca GM. Análisis causa-raíz sobre evento adverso producido en la Clínica Odontológica Docente Asistencial, Facultad de Odontología, Universidad de La Frontera, Chile. Int J Odontostomatol 2017; 11:207-16., and the implementation of educational programs could benefit the necessary development of dentists’ prescribing skills ⁹⁸98. Guzmán-Álvarez R, Medeiros M, Lagunes LR, Campos-Sepúlveda A. Knowledge of drug prescription in dentistry students. Drug Healthc Patient Saf 2012; 4:55-9.^,9999. Mahmood A, Tahir MW, Abid A, Ullah MS, Sajjid M. Knowledge of drug prescription in dental students of Punjab Pakistan. Pakistan Journal of Medical and Health Sciences 2018; 12:232-7..

Quality improvement methodologies tend to favor patient safety ²⁹29. Akifuddin S, Khatoon F. Reduction of complications of local anaesthesia in dental healthcare setups by application of the sixsigma methodology: a statistical quality improvement technique. J Clin Diagn Res 2015; 9:ZC34-8.^,9797. Rivera-Mendoza F, Acevedo-Atala C, Perea-Pérez B, Labajo-González E, Fonseca GM. Análisis causa-raíz sobre evento adverso producido en la Clínica Odontológica Docente Asistencial, Facultad de Odontología, Universidad de La Frontera, Chile. Int J Odontostomatol 2017; 11:207-16.. For example, the clinical audit is a useful tool, especially if: (i) it is structured formally and continuously with a regular schedule of meetings and events with permission for direct vertical and horizontal communication; (ii) training includes a significant number of staffers; (iii) it is aligned with local priorities; (iv) there is follow-up of all its phases (recording, data collection, data analysis, and report); and (v) there is timely monitoring of each recommendation in the action plan and its conclusion is reached before the next audit cycle is executed ¹⁰⁰100. Ashley MP, Pemberton MN, Saksena A, Shaw A, Dickson S. Improving patient safety in a UK dental hospital: long-term use of clinical audit. Br Dent J 2014; 217:369-73..

Another available tool is risk analysis. For patients with motor and/or cognitive needs that require specific care, Perea-Pérez et al. ⁵⁷57. Perea-Pérez B, Labajo-González E, Bratos-Murillo M, Santiago-Sáez A, Albarrán-Juan E, Villa-Vigil A. The clinical safety of disabled patients: proposal for a methodology for analysis of health care risks and specific measures for improvement. Med Oral Patol Oral Cir Bucal 2013; 18:e251-6. proposed a specific risk analysis, which considers the risks related to patients and those associated with the professionals and the healthcare setting.

Reports of incidents constitute an excellent source of organizational learning and serve as substrate for the elaboration of strategies and interventions to improve patient safety ²⁸28. Jonsson L, Gabre P. Adverse events in public dental service in a Swedish county: a survey of reported cases over two years. Swed Dent J 2014; 38:151-60.. Authors that used mixed databases, that is, that involved reports on health areas in general suggested that a specific reporting system for dental patients could facilitate both reporting and subsequent analysis of these events ¹²12. Thusu S, Panesar S, Bedi R. Patient safety in dentistry - state of play as revealed by a national database of errors. Br Dent J 2012; 213:E3..

However, it is necessary to develop institutional policies to reduce barriers that hinder reporting by professionals ¹²12. Thusu S, Panesar S, Bedi R. Patient safety in dentistry - state of play as revealed by a national database of errors. Br Dent J 2012; 213:E3.^,6666. Leong P, Afrow J, Weber HP, Howell H. Attitudes toward patient safety standards in U.S. dental schools: a pilot study. Dent Educ 2008; 72:431-7.^,7575. Renton T, Master S. The complexity of patient safety reporting systems in UK dentistry. Br Dent J 2016; 221:517-24. and to involve patients and their families, encouraging them to report harms ¹⁰¹101. Hiivala N, Mussalo-Rauhamaa H, Murtomaa H. Can patients detect hazardous dental practice? A patient complaint study. Int J Health Care Qual Assur 2015; 28:274-87.. Population awareness-raising of the problem is also important in the policies’ wider sphere ¹⁰²102. Ibrahim NK, Alwafi HA, Sangoof SO, Turkistani AK, Alattas BM. Cross-infection and infection control in dentistry: knowledge, attitude and practice of patients attended dental clinics in King Abdulaziz University Hospital, Jeddah, Saudi Arabia. J Infect Public Health 2017; 10:438-45..

Many AE could be avoided by maintaining precise patient records ¹⁰³103. Hiivala N, Mussalo-Rauhamaa H, Murtomaa H. Patient safety incident prevention and management among Finnish dentists. Acta Odontol Scand 2013; 71:1663-70.. Informed consent attached to the patient file has proven valuable by placing the patient at the center of the treatment decisions ¹⁰⁴104. Robinson FG, Fields HW, Ness GM, Heinlein DJ, Gellin RG, Larsen PE. Development and implementation of a uniform dental school-wide electronic treatment consenting process for patients. J Dent Educ 2018; 82:949-60.. Adding photos and X-rays to the patient chart, recording situations pertaining to the incidents, as well as lab test results, can by highly useful in the analysis and assessment of AE ⁴¹41. Pérez Gómez W, Pita Bejarano AM, Ramos Vargas CA, González Moncada J, Güiza Cristancho EH, Rodríguez Ciódaro A. Análisis de los eventos adversos em el área de rehabilitación oral de la Facultad de Odontología de la Pontificia Universidad Javeriana Bogotá. Univ Odontol 2017; 36(77). https://revistas.javeriana.edu.co/index.php/revUnivOdontologica/article/view/20829.
https://revistas.javeriana.edu.co/index.... .

Still, patient safety in Dentistry is multifactorial and complex ⁹9. Yamalik N, Perea-Pérez B. Patient safety and dentistry: what do we need to know? Fundamentals of patient safety, the safety culture and implementation of patient safety measures in dental practice. Int Dent J 2012; 62:189-96.. The proposed solutions assume strong organizational action and teamwork. Such structural conditions are not always favorable, due to the inherent characteristics of dental care provision itself or other organizational factors.

Research efforts are thus explicitly needed in patient safety in Dentistry, aimed at assisting the systematization and organization of the provision of care and helping reduce AE in the field.

Study limitations

The study presents some limitations. The integrative review is an important tool that allows analyzing the literature widely and systematically. However, the search terms in the databases only included English, Portuguese, and Spanish, which may have limited the number of articles retrieved. Another limitation related to the search terms is the fact that they did not include the MeSH term adverse events, widely used to index publications on patient safety. To mitigate this issue, the authors expanded the search beyond the MeSH terms used, including the term patient safety in titles and abstracts, which allowed retrieving studies published since 2005. The use of only three reference databases may also have introduced a bias, although the authors felt that the three databases cover the major research output in the health field. In the literature search, 13 articles were excluded. Seven of these did not present an available abstract and 6 were inaccessible. Thus, the review did not include potential findings from the 13 studies. In the attempt to minimize these biases, 9 more articles were included, based on analysis of the references from the retrieved articles.

Conclusion

The publications showed that Dentistry is evolving towards better knowledge of patient safety issues, especially in developed countries. The possibility of collecting studies with diverse methodologies and objectives contributed to describing their actual role in the theme and allowed identifying a range of proposals for improving patient care safety.

Healthcare’s complexity includes factors inherent to the setting and to human action, which in Dentistry amplifies the odds of AE through single and fragmented work. Shaping a favorable environment for patient safety in dentistry requires involvement by universities, industry, and the services’ administration, together with the healthcare professionals directly providing the care, the patients, and their families. In this sense, qualitative studies proved quite useful, although few in number in this review.

As in other professions that produce the direct fruits of human labor, the results of the care depend largely on the attending professional. Thus, training, ergonomics, sufficient time to conduct the care, and appropriate operational inputs were identified as crucial for the real work to approach the ideal and reduce the risk of harms to dental patients.

The trend in research according to the components of the cycle proposed by the WHO showed that studies dedicated to the first phase, namely measuring the harm, were not the majority. The main AE in Dentistry were: hard and soft tissue lesions to the oral cavity, with special attention to switched tooth extractions; allergies, anesthetic complications, and infections, circumstances which if aggravated can even lead to death. Many studies addressed the importance of understanding the causes of AE and identifying solutions to avoid them, in an effort to mitigate the problem.

Contributing factors included failures in planning and management of care, ineffective communication, inadequate use of technologies, deficiencies in training, and a weak safety culture. The study instruments’ proposals and the methods presented to decrease the problem’s impact require further assessment studies.

Finally, only two studies classified in the last phase of the cycle transpose to practice the measures assessed as having a positive impact and improving patient safety. These findings confirm Dentistry’s participation in this area, but point to a long road ahead, suggesting fertile ground for research to help improve quality and safety in dental care.

References

Publication Dates

History