With increased volume comes increased risk; learning from ‘never events’
As part of my role as Adjunct Faculty with the Royal College of Surgeons in Ireland, I am involved in delivery of content across many programmes including Quality and Safety in Healthcare. This broad term covers a range of important aspects of healthcare delivery, in many settings including primary care, community and hospital. Current thinking in this field tends to be driven by data collected from many sources, particularly at adverse events and near miss events. A look at the NHS in particular is worth mentioning.
NHS Improvement is an essential guidance group that looks at ways of monitoring and setting standards within healthcare. Over the past decade, they have looked at ‘never events’. They described never events as: “Serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. Strong systemic protective barriers are defined as barriers that must be successful, reliable and comprehensive safeguards or remedies – for example, a uniquely designed connector that stops a medicine being given by the wrong route. The importance, rationale and good practice use of relevant barriers should be fully understood by and robustly sustained throughout the system, from suppliers, procurers, requisitioners, training units to frontline staff…”
The most recent iteration of the Never Events Framework and Policy (2018) was updated in November 2020. The framework details a methodology in how never events are categorised and reported. This led to the development of a ‘Never Events List’. From a general dental view point, they specifically mention the extraction of the incorrect tooth. This falls broadly under the ‘Wrong Site’ methodology. Interestingly, they exclude deciduous teeth from the definition, and also incorrect local anaesthetic site administration too.
The creation of a list of never events can seem overly prescriptive, and clinicians can find it patronising or suffocating. Standardising protocols for delivery of care can also seem mundane, humdrum and the preserve of those who aren’t out in the ‘real world’ with ‘boots on the ground’.
From experience, I always quote a self-developed protocol which underlines what many fellow GDPs do. Over the years, the ingenuity and sheer common-sense approach that GDPs adopt and develop has stood us all in good stead.
Occasionally, a patient is referred back to the dentist for tooth removal as part of an orthodontic treatment plan. Typically, these are first premolar or second premolar teeth. More often than not, these teeth are virginal without any restoration, decay or obvious defect.
A protocol which many adopt is to schedule that patient at the beginning or end of a clinical session. This allows you to give undivided attention without the ever-present distraction of a busy waiting room. With this in place, when the patient attends, I would routinely ask the dental nurse to verbally call out the instruction from the orthodontist. And then, with the nurse closely observing the patient’s mouth, I would take a HB pencil, and carefully ‘shade’ the indicated (dried) tooth. Next, a further tooth count/chart, calling out the teeth as I move back along the arch to the ‘shaded’ tooth. With agreement from the nurse, a closer inspection of the periapical radiograph, a re-read of the instruction and double check of patient’s details – then the extraction could proceed (with good local anaesthetic on board, obviously!). Where the patient was under the age of consent, I would encourage the parent/guardian to be present for the above. The above may sound like a West End production – but it instils confidence in the patient (and parent), assists in treatment and copper-fastens consent.
The above also mirrors what happens during hospital theatre lists with the ‘Time-Out’ protocol. This technique is defined as “an immediate pause by the entire surgical team to confirm the correct patient, procedure, and site.”
With the impending roll out of vaccines, and much longed for return of some normality, our surgeries should get increasingly busy. With increased volume comes increased risk. We have learned much from our supplemented cross-infection control protocols during this pandemic.
And the hope is that with the learning from these and other protocols, they will help us to continue to improve in our delivery of the highest quality care for our patients as demand for our professional skills increases once more.