CDA Essentials 2018 • Volume 5 • Issue 1

Dr. Elsbeth Kalenderian, the lead author of the study and chair of the department of preventive and restorative dental sciences at the University of California San Francisco School of Dentistry, says the study addresses a knowledge gap in patient safety. “There is a lot of information about patient safety in medicine, but not much yet in dentistry. That is why we wanted to create an adverse event inventory. We asked providers, ‘What do you see every day when you treat patients?’” The study identified 540 unique causes that might lead to an adverse event. Some of the reported causes related to human failures were “rule-based errors,” (43%, e.g., practising beyond the scope of training), followed by “skill-based active errors” (22%, e.g., obstructing the airway when making an impression) and “knowledge-based active errors” (13%, e.g., failure to diagnose). Participants reported 747 unique adverse events to researchers. The most frequently noted adverse events were “wrong-site, wrong-procedure and wrong-patient errors” (16%, e.g., endodontic treatment of nonrestorable teeth), “hard tissue damage” (15%, e.g., bone fracture during extraction), and “soft-tissue injury” (13%, e.g., lip laceration incurred during dental procedure). Dr. Kalenderian hopes the study will lead to safer patient care. “We need to start thinking about how we can prevent these adverse events. What are the underlying issues? Once we identify the issues that lead to these events, we can work on preventing them. That’s our hope in all of our patient safety work.” a Reference 1. Maramaldi P, Walji MF, White J, Etolue J, Kahn M, Vaderhobli R, et al. How dental team members describe adverse events. J Am Dent Assoc. 2016;147(10):803-11. I ssues and P eople 23 Issue 1 | 2018 | Dr. Elsbeth Kalenderian A 2016 study shed light on unintended patient harms that occur during the delivery of dental care. 1 Based on interviews with 76 participants (dental faculty, dental residents, students and dental clinical staff members), researchers identified a wide range of adverse events, which they defined as “ harm caused to the patient by dental care, regardless of whether it is associated with an error or is considered preventable.” To hear Dr. Kalenderian discuss the study, visit oasisdiscussions.ca/ 2016/11/07/ddav If an Adverse Event Happens in Your Practice Disclosure of an adverse event—whether critical or not—is required as part of the duty of all Regulated Health Care Professions. Excerpt from the 2010 CDA document, Disclosure of Unanticipated Outcomes: A Toolkit for Dentists “Disclosure should occur when harm has occurred, when there is potential for harm after an incident or when a reasonable person would want to know about the incident under the circumstances. For example, would you want to know if a similar incident occurred during your own care or during the care of your child or elderly parent? It is recognized that adverse events will vary in gravity. The complexity of the disclosure process will depend on the potential seriousness of the consequences.” To view the CDA toolkit, see: cda-adc.ca/adverseeventstoolkit