Source · HSSIB Patient Safety Investigation
Wrong site surgery – wrong tooth extraction
Published 27 April 2021
Launched 3 March 2020
Published
HSIB Legacy
Checking
Surgical
Wrong tooth extraction is the most common form of wrong site surgery reported over the past five years. This is classed as a Never Event - patient safety incidents that are wholly preventable where guidance or safety recommendations are available at a national level and have been implemented by healthcare providers.
Summary
3 recommendations
1 action
4 learning prompts
1 of 3 responded
Safety Recommendations
A/2021/037
NHS England
HSIB recommends that NHS England and NHS Improvement should review the Never Events policy and framework and include content to explicitly define the criteria that need to be satisfied for any control to be considered a ‘strong systemic protective barrier’.
NHS England has commenced a programme to review the Never Events policy and framework, including exploring criteria for a 'strong systemic protective barrier'. This review is an ongoing process.
Response received 7 July 2021
We agree that the systemic barriers for some Never Events are not as strong as others and following on from CQC’s thematic review ‘Opening the Door to Change’ commenced a programme of work to review the list of Never Events to identify which barriers are not as strong as was initially thought. Part of this review is also to explore the criteria for a strong systemic protective barrier to identify if this can be clearly defined. The review of the Never Events Framework and Never Events List will continue to be an ongoing process, as it has been since its first iteration in 2009. We are grateful to HSIB for this recommendation which will continue to support this review process. We note that the HSIB report also records a safety action A/2021/037 “NHS England and NHS Improvement has reviewed ‘wrong tooth extraction’ against the criteria for a Never Event (as set out in the Never Events policy and framework) and, after due consideration, has removed it from the list of published Never Events with effect from 1 April 2021.” HSIB defines Safety Actions as “actions required during an investigation to immediately improve patient safety”. The removal of ‘wrong tooth extraction’ from the detailed definition of wrong site surgery was made in the Never Events List revised in February 2021. As we know HSIB appreciates, this change arose from workstreams commenced after ‘Opening the Door to change’ was published, including workshops with experts in dental surgery that we invited the HSIB investigators to attend. This change was motivated by the need to focus investigation where it can be most effective rather than any immediate patient safety concerns. Response received on 7 July 2021.
R/2021/111
It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers.’
and
‘
No response published on HSSIB's website
R/2021/112
It is recommended that NHS England and NHS Improvement develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barriers are felt to be possible but are not currently available.’
(Healthcare Safety Investigation Branch, 2021)
6.9 This investigation into wrong tooth extraction found a consensus in the literature review that a barrier should be reliable and adequate as a primary defence to stop a threat developing into an unwanted event and outcome. By using a system of barrier management to investigate and analyse the process of tooth extraction in the outpatient setting, the investigation found that the controls in LocSSIPs intended to prevent wrong tooth extraction were reliant on human elements to make them effective. They often had none of the systemic assurances and ownership expected of a barrier in other safety-critical industries. They lacked independence and used layers of safeguards in an attempt to achieve a level of reliability. When considering the effectiveness of controls, an external review of Never Events at a trust noted:
‘… given the operating dental surgeon appears to have carried out all the recommended safety precautions noted in the NHS England guidance prior to operating and yet the incident still occurred, it would seem that this serious incident was inadvertently categorised as a ‘Never Event’.’
(Oxford University Hospitals, 2016)
While there were many safeguards to prevent wrong tooth extraction, the investigation did not identify any ‘strong, systemic barriers at a national level’ which made this form of serious incident ‘wholly preventable’.
6.10 Following inclusive discussions between the NHS England and NHS Improvement safety team, key stakeholders representing dental professionals and HSIB in November 2020, it was agreed that wrong tooth extraction did not meet the criteria for a wrong site surgery Never Event. NHS England and NHS Improvement announced in February 2021 that wrong tooth extraction would be removed from the list of Never Events, effective as of April 2021.
No response published on HSSIB's website
Safety Actions
Action 1
Action
NHS England and NHS Improvement has reviewed ‘wrong tooth extraction’ against the criteria for a Never Event (as set out in the Never Events policy and framework) and, after due consideration, has removed it from the list of published Never Events with effect from 1 April 2021.
Learning Prompts
Prompt 1
Learning prompt
Dentists – who are qualified to treat diseases and other conditions that affect the teeth and gums, especially the repair and extraction of teeth and the insertion of artificial ones. Dentists may register specialist skills on 13 specialist lists regulated by the GDC which include orthodontics (the specialism dealing with irregularities or abnormalities in the teeth or jaw) and paediatric (children’s) dentistry.
Prompt 2
Learning prompt
Dental therapists (DTs) – who have a scope of practice that is greater than that of a dental nurse (DN) (see below), but more limited than that of a dentist. For example, a DT may undertake dental examinations and charting, take radiographs (X-ray images), give dental block analgesia, carry out fillings on deciduous and permanent teeth, and extract deciduous teeth under local anaesthetic.
Prompt 3
Learning prompt
Dental hygienists – who carry out treatment which helps patients maintain their oral health by preventing and treating periodontal disease and promoting good oral health practice. Many dental hygienists also have an additional qualification as a dental therapist; this was true of the dental therapist in the reference event.
Prompt 4
Learning prompt
Dental nurses (DNs) – who provide clinical and other support to the team, including dentists and dental therapists.