F E AT URE D E N TAL RIS K N


HS Improvement defines ‘never events’ as “serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers” – which is rather a mouthful. Press reports of catastrophic errors such as


removing a healthy kidney in place of a diseased one or amputating the wrong leg may seem to stretch credulity. And yet such things happen in the most up-to-date and “efficient” operating theatres. It has been estimated that one out of four orthopaedic surgeons in practice in the USA for more than 25 years will have performed at least one wrong-site surgery. The concept of ‘never events’ was introduced in the NHS in England in April 2009, following a proposal by Lord Darzi in his report High Quality Care for All. Today all commissioners and providers of NHS care in England are required to report ‘never events’ for a list maintained by NHS Improvement. Statistics are collated and published regularly. In the year to March 2017, a total of 445 ‘never events’ were reported – and of these 42 per cent were classified as wrong-site surgery with the greatest number (46) being “wrong tooth/teeth removed”.


SURGICAL CHECKLIST The dental never event is a relatively new concept. Indeed, it was only in 2015 that wrong tooth extraction was first considered to be a never event as defined by NHS Improvement. Just how meaningful that 46 figure is could be debateable given this mainly includes reported incidents from secondary care. How many wrong tooth extractions go unreported in general dental practice is uncertain, but we can only assume the scale of such errors is of potentially greater magnitude. Back in 2009 when the then National Patient Safety


Agency first began compiling data on never events it was also in the process of implementing the World Health Organisation’s (WHO) Surgical Safety Checklist in every hospital in England and Wales. The checklist was devised by the WHO after a year-long global pilot of nearly 8,000 surgical patients across eight countries. The findings from this pilot study were compelling – adherence to the checklist resulted in a one-third reduction in surgical deaths and complications. Later in 2015 NHS England introduced its own National


Safety Standards for Invasive Procedures (NatSSIPs) which build on the existing WHO surgical checklist. NatSSIPs offer healthcare professionals general advice on how they can enhance best practice through a series of standardised


WRONG-SITE EXTRACTION


It happens more often than you think – but some simple measures can help avoid this disastrous outcome


14 / MDDUS INSIGHT / Q2 2018


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