This is the first paper the authors are aware of that provides an analysis of all patient safety reported incidents over a five-year period from a primary care dental provider in the UK, where the majority of clinical care is delivered by undergraduate students in training. Despite the provider having a pro-active reporting culture, where there is a clear clinical incident policy and encouragement given to report all incidents no matter how minor, overall incidents rates were low and no serious untoward incidents (SUIs) or never events occurred during the reporting period. Of the main categories which were of interest from a patient safety perspective, overall clinical incidents were low with a rate of 1.5 per 1,000 appointments and were even lower for near miss incidents (0.9 per 1,000 appts), contamination injuries (0.9 per 1,000 appts) and complaints (0.3 per 1,000 appts). There is no comparable data in the literature to judge these rates or benchmark them despite there being several similar clinical settings around the UK delivering dental undergraduate training in a primary care environment. While the rates reported within the PDSE setting appear low, comparable data is required from similar settings to draw more meaningful conclusions.
The data collected by the reporting system is analysed monthly, with senior clinical leadership ownership, to identify trends that may warrant further investigation. Depending on the outcome of the subsequent root cause analysis, this may lead to changes in clinic procedures, protocols or teaching guidance which is fed back to educators, who adjust teaching and assessment processes to prevent re-occurrence.
One area highlighted by incident data in 2017-18 was hypochlorite incidents, where a number of reports indicated patients could taste hypochlorite during irrigation stages of root canal procedures. These were not hypochlorite incidents per se (i.e. leakage into soft tissue) but minor leakage in rubber dam isolation. In response a ‘Prevention and Management of Sodium Hypochlorite Accidents Standard Operating Procedure’ (SoP) was developed and introduced in 2018, outlining a six-point prevention protocol, including procedural considerations and more guidance on management techniques to achieve an adequate dam seal. Through this new process the undergraduate student clinic handbook was updated, and caulking techniques, which previously were not formally assessed in the simulated clinical environment, were introduced as a new assessment stage. These measures have helped to reduce the incidence of hypochlorite leakage and following its introduction we observed a statistically significant fall in the number of clinical treatment incidents reported between 2017-18 and 2018-19. The learning from this has improved clinical dental education and improved outcomes for patients.
Another example of this process in action from 2020 was the introduction of an enhanced clinical refresher at the start of every academic year. The incident data showed a notable rise in incidents reported in the September – November months of each academic year (Figure 3). Further interrogation of the data highlighted that these incidents were categorised as radiography retake incidents, coinciding with the return of undergraduate students to clinical work after a period of leave over the summer break. Learning from this analysis resulted in the introduction of more comprehensive re-induction sessions, including radiography refreshers, as well as lunch and learn sessions throughout the academic year, which saw a reduction in this specific incident occurrence.
The peak in incidents from September to November in the academic year 2021-22 (Figure 3) coincided with the introduction of a new dental laboratory provider, which resulted in new laboratory processes for all clinicians and students to learn, and due to the high number of items of laboratory works processed each day, led to an increase in incidents reported. All staff and students were encouraged to incident report any challenges they faced in the transition to the new lab, which explains the statistically significant increase in all reported incidents between the years 2020-21 and 2021-22, as part of this process.
Analyses concluded there was no significant difference in the rates of soft tissue injuries between 2017 and 2022. Whilst the data reported that soft tissue injuries do occur, these incidents are managed well with no further complication. As noted by El Sayed et al,(11) soft tissue traumas were the most common complication of endodontic procedures, from the rubber dam isolation stage, where students were learning to conduct endodontic treatment on patients exhibiting limited mouth opening, excessive salivation or tooth misalignment. These sorts of challenges, addressed locally, are necessary in enhancing undergraduate competency during clinical training years and to some degree are to be expected.
Analyses also showed no significant difference in the rates of written complaints between each year in the reporting period. Whilst this may be surprising given the generalised reported increase in dental complaints, one ofthe key factors in many complaints externally is related to costs of treatment and fees. (12,13,14) In one study,(15) almost 20% of complaints in a dental school environment across a four-year period were associated with expenses, with the predominant category of complaint (34%) usually to do with appointments (scheduling, timings). PDSE however does not raise any patient charges in its provision of primary care dentistry, and this may be a contributing factor as to why the complaints rate remains low and stable across the reporting period.
Across the reporting period, fewer incidents were reported across the months of December, April, July and August, which correspond with undergraduate holiday periods. PDSE is a primary care and education-based provider, so during these times clinics are staffed with qualified clinicians, hence the reduction in all reported incidents. Similarly, the fall to zero across April – August for the years 2019-20 coincide with reduced clinical activity during the Covid-19 pandemic.
Creating an open and transparent culture is a fundamental requirement for any clinical organisation or provider striving to optimise outcomes for patients. PDSE’s incident reporting policy encourages and empowers all members of the team to report incidents they may experience or observe, creating a safe and open environment for all stakeholders, where the cultural aspects of patient safety are a shared and supportive responsibility shared across the entire dental team. It appears that this culture is being increasingly taken up within PDSE as whilst many incidents are still reported by PDSE staff or final year dental students, an increasing variety of junior students and colleagues are reporting incidents every year (Figure 2). This empowerment of the entire dental team is in in line with the outcomes of the National Advisory Board Human Factors in Dentistry report in the context of incident reporting and learning from mishaps.(7) Similarly, Getting It Right First Time (GIRFT) is a key national programme which advocates for a ‘shoulder to shoulder’ approach in supporting departments and NHS Trusts, across a wide range of hospital specialities to improve their internal processes, cultures and outcomes, therefore empowerment of the entire team feeds into these long term goals.(16) The first stage of their six phase process is gathering local data, which is imperative to enable departments to compare their local performance with national data in phase two and identify areas to improve in phase three.
Reporting of ‘near misses’ is also equally important, allowing organisations to identify trends and establish a need for support, thus allowing them to react in real time to the needs of students and employees.(7) As shown by colleagues(17) exploring sharps safety in undergraduate dentistry, the narratives recorded around each incident are important to analyse in order to highlight factors that might lead to recurrence. The undergraduate dental clinic is primarily a learning setting, where students develop their professional attitudes,(18) learn procedures and protocols which will endure throughout their practicing career, thus opportunities to capitalise on learning in this environment are paramount.
Sharing this learning establishes an educational feedback loop from the incident reporting process. Whilst effective local incident reporting can improve local clinical team behaviours, this information is vitally important to share publicly, to raise awareness and allow other dental teams to adapt their own clinical behaviours.(17) As with primary care, there are however many reported barriers perceived by clinical supervisors in engaging with incident reporting systems.(19) These include a lack of confidentiality, undesirability of being held responsible, a lack of support from the academic community and unresponsive management teams, possible negative relationships with students and not wanting students to be subjected to disciplinary procedures.
PDSE approaches this by sharing a monthly patient safety bulletin with all members of the organisation, dental staff, and students. Anonymised incidents are described, the key learning highlighted and changes to policy or practice explained in clear and non-judgemental language. Development of reporting systems which are focused on learning, rather than exposure and blaming operators,(20) without any punitive associations, are imperative in helping students to understand their ongoing role in identifying and reporting incidents.(18) Through regular communication and ‘setting the patient safety tone’ (21) of the organisation, behaviour change is encouraged. In addition, key clincial incidents are discussed in regular meetings to ensure important learning points are discussed, reinforced and reflected upon, creating an informal survelliance system to prevent re-occurrence. This is particularly important as the provider is multi-sited which creates additional challenges in dissemination of learning and cultural development.
Studies have also shown a chronic trend of underreporting of incidents from primary care dentistry.(4) In a review of reported incidents between the 2005-2014 period, it was found that there were only 3 reports originating from general dental practice, of which there were 10,300 registered in the UK. (10) There are a number of notable barriers to patient safety incidents being reported more widely in primary care. (4,6,22,23) These can be summarised into three broad categories: a lack of knowledge and understanding, the reporting systems themselves and other factors.(7) Primary care teams are unclear about what incidents need reporting and to whom, and the learning from reporting these events hasn’t been shown to sufficiently benefit patients or the practitioners. Recent research to establish the attitudes of clinicians to patient safety highlights the lack of knowledge concerning reporting, particularly of those colleagues in primary care, as well as the fear of repercussions of reporting.(24) A standardised reporting system doesn’t exist across the primary care dental profession, so the complex processes and numerous bodies involved become a barrier to clinician reporting. As noted by Ensaldo-Carrasco et al,(25) the emerging evidence regarding patient safety, its incorporation into evidence-based guidelines and creating of clear reporting systems, offers many opportunities for improvement in the field of dentistry.
Strengths and limitations of the work
This work looks retrospectively at reported data over a five-year period (2017-2022) from a primary care-based provider. It highlights the importance of fostering a patient safety culture within our education-based settings, to promote an enduring relationship with patient safety and incident reporting throughout the practising careers of graduating students. This work also highlights the benefits of learning from incident reports, and being able to implement new strategies, in real time, to improve patient outcomes. There is a lack of comparable data published from similar settings so comparison to other settings is not possible. We would encourage more settings to openly publish their data to enable learning to be shared across organisations.