safety checks and education and training. The standards also support NHS providers to work with staff to develop and maintain their own, more detailed Local Safety Standards for Invasive Procedures or LocSSIPs. Recently a working group of dental bodies including


the Faculty of Dental Surgery and the Faculty of General Dental Practice produced a toolkit for developing LocSSIPs to avoid wrong-site extraction (tinyurl.com/ y9gxnbw8). The toolkit is aimed at all clinical dental teams involved in dental extractions and its developers acknowledge that wrong-site surgery in dentistry may not be on a par with the loss of a limb or major organ but it can still be devastating for both patient and clinician.


TIME OUT


A significant number of errors in the operating theatre or surgery – including wrong-site surgery – result from a lack of communication both with the patient and among the clinical team. In addition there may be no established procedures and/or procedural compliance to avoid wrong- site extraction. The LocSSIPs are intended to provide safety critical steps to address these issues. The process begins even before the patient arrives with


first-stage consent undertaken prior to the appointment and confirmed on the day of the procedure. It calls for the treatment plan to be stipulated clearly using Palmer notation, with a written description of the teeth being extracted. A safety briefing with staff should also be undertaken, addressing specific issues including diagnosis and planned procedure, site and side, relevant comorbidities, need for antibiotic prophylaxis and equipment requirements. Once the patient is in the chair, the dentist should


recheck name, date of birth and address, and consent should be confirmed. They should also again check tooth notation and ensure it is clearly documented on the consent form, checklist, whiteboard or computer screen, which is clearly visible to the surgeon and team for verification during surgery. A ‘pause’ or ‘time out’ is then advised before administering anaesthetic and starting the procedure. The time out should be conducted by a team member with all other tasks halted. This again is to confirm: • • •


correct patient


correct treatment plan correct site.


Verbal counting of the dentition from midline is


recommended to confirm surgical site using an instrument pointed at each tooth, with verification from an assistant (of side and countdown). Once the tooth has been extracted there should be a systematic check that nothing has been lost or retained during the procedure, such as bur heads, cotton wool or tooth fragments. This protocol can be varied to reflect work carried out in general/specialist practice, including care provided under conscious sedation, but the fundamental principles remain the same. Often surgical errors occur due to unanticipated interruptions during a procedure. The LocSSIPs advise that with any interruption, the surgeon should “repeat the ‘three Rs’: Reposition; Recheck; Reaffirm with your assistant”.


A debriefing is encouraged post-procedure, including consideration of things that went well, any problems with equipment or other issues that occurred and areas for improvement. A record of this debrief should include an action log with any significant issues identified and recorded in the patient notes. The British Association of Oral Surgeons (BAOS)


provides guidance on its website in regard to the LocSIPPs process for wrong-site extraction. Here it advises that in mitigating such risks it is critical that dental teams develop checklists appropriate to their specific clinical environment and provide adequate training for staff in implementation and use. There should also be active audits of the processes involved to ensure that checklists are being used correctly and that teams can learn from mistakes – including investigation and root-cause analysis. Any “punitive” action should be avoided when incidents do occur to encourage openness.


REPORTING NHS organisations across the devolved UK nations are keen to ensure that lessons are learned from serious clinical errors. In England never events must be reported to both the Strategic Executive Information System (StEIS) and the National Reporting and Learning System (NRLS) – although currently a new patient safety incident management system is being developed. Find out more on the NHS Improvement website. Deliberate failure to report a never event is likely to constitute a serious failing and breach of Care Quality Commission (CQC) requirements. Recently the Scottish Government launched a new duty of candour for all health, care and social work services setting out how organisations should respond when there has been an unexpected or unintended incident resulting in death or harm. This includes notifying the person affected and providing an apology and account of what happened. Organisations must also publish and submit an annual report on when the duty has been applied and what learning and improvements have been put in place in response. Northern Ireland also has its own reporting


requirements through the Regulation and Quality Improvement Authority (www.rqia.org.uk). Given the media coverage they often attract, instances


of wrong-site surgery remain rare. One case reported in the BMJ concerned a healthy 23-year-old man who presented for cataract surgery. In pre-op he expressed some concern that the surgeon was clear which eye was to be operated on. Later after numerous routine site verifications the patient lifted his surgical cap and said: “Had I realised all these steps would be taken, I wouldn’t have done this.” Shaved into the short hair on the side of his scalp was a large arrow pointing to the correct eye – better safe than sorry!


Jim Killgore is managing editor of Insight magazine


LINKS/SOURCES • British Association of Oral Surgeons – Help and Advice for Professionals http://www.baos.org.uk/ for-professionals/ • NHS Improvement – Never Events policy and framework https:// improvement.nhs.uk/ resources/never-events- policy-and-framework/ • Scottish Government health policy – Duty of Candour http://www. gov.scot/Topics/Health/ Policy/Duty-of-Candour


MDDUS INSIGHT / 15


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