Human error is inevitable in any walk of life. But in dentistry, where one slip has the potential to cause lasting harm to a patient, the stakes are higher. In an ideal world, every conscientious dental professional would have the time, space and support to treat patients. They would never be fatigued, under time pressure because of a full waiting room, their usual dental nurse would always be in attendance, equipment would operate perfectly and every patient would be calm personified.
Of course, the reality of clinical practice is far from perfect, but even so, most dental professionals still expect to be on top of their game in every appointment. The problem is that it's hard to consider how factors like tiredness or poor team communication contribute to human error if you don't accept that making a mistake is inevitable. And sadly, when adverse incidents do occur, dental professionals have had good cause to fear being blamed, investigated or sued – when in fact it would be better for everyone to find out what went wrong, and to learn from it.
What are human factors?
Professor Simon Wright believes that a better understanding of human factors in dentistry is key to stepping away from these well-worn and unhelpful patterns and thereby improve patient safety. The idea is to examine why errors occur and then develop strategies to 'absorb' the risk by improving work systems, processes and technological innovation. 'If I was to define the study of human factors, it's about enhancing clinical performance through understanding the effects of things like teamwork, task management, the culture and human behaviour in a clinical setting,' says Simon.
However, this approach first requires the profession and regulators to acknowledge that every individual, no matter how well trained, motivated or dependable, is fallible. Simon first became interested in human factors after attending a talk on the subject by dentist and private pilot, Franck Renouard. 'He began by saying that around 80% of plane crashes were caused by human error, rather than technical problems with aircraft,' remembers Simon. 'And it turned out that the ratio was similar for complications in healthcare.'
Under-reporting of errors
But while Renouard went on to explain how the aviation industry had embraced human factors research as a means to improve safety, the dental profession has some way to go. And one difficulty has been that dental professionals have been frightened to admit to a mistake.
While reporting adverse incidents is expected and mandatory for 'never events' like wrong tooth extraction, dentistry only accounts for a small proportion of reported national patient safety incidents – just 1,126 out of more than 2 million reports in the year to March 2019.
'I did a research project asking dentists to report what errors they made over a week,' reveals Simon. 'And I had responses back like, 'I chose the wrong shade of a tooth' or 'I forgot to put the date on a lab sheet' – all things that were very low grade and couldn't get them into any trouble.
'So really, the first thing we have to do is create a culture within dentistry where we all understand that we make errors and learn from them, rather than try to hide the fact we are making them because of the possible consequences. And I think engaging with the GDC is a big part of that cultural change. After all, the GDC's main role is to protect patients, so preventing human errors that have the potential to cause harm should be a big part of their work.'
It's important to understand that human factors interventions don't work as a bolt-on. We need to be instilling human factors principles into everyday practice.
The role of the regulator
To its credit, the GDC has recognised that Simon's call for cultural change complemented its own effort to 'shift the balance' towards a more proportionate and supportive system of regulation that emphasises prevention, rather than focusing on fitness to practise investigations. And it was quick to support the National Advisory Board on Human Factors in Dentistry (NABHFD) which Simon established in July 2018 to raise awareness of human factors and the value of an open and just culture in improving patient safety. Other members include UK Committee of Postgraduate Dental Deans and Directors (COPDEND), the Chief Dental Officers (CDOs), Care Quality Commission (CQC) and the DDU.
'We talk about the strategies that we can put in place to help drive forward the study of human factors,' Simon explains. 'It's important to understand that human factors interventions don't work as a bolt-on. We need to be instilling human factors principles into everyday practice, rather than just adding a human factors module to the syllabus in dental schools.
'Take checklists, for example. It's not enough to have a lecturer saying you need to use them. You need checklists to be embraced by the whole dental team in a systematic way and used routinely. It needs to be like a car seat belt, in that you just put it on without thinking every time and not treat it as a box ticking exercise.'
Practical steps and tools
At a practice level, Simon says one of the most important things that dental professionals can do to reduce the likelihood of human error is to make sure everyone in the dental team is prepared to speak up the moment they see something about to go wrong. 'The concept of the authority gradient has come from the work of Martin Bromiley', he says, referring to an airline pilot who became a patient safety campaigner after his wife died because of errors during a routine operation. 'It exists in a lot of old-school practices where a dental nurse would never dream of saying, 'That's not the right tooth' or, 'That patient is allergic to penicillin'. One of the key changes we can make is to reduce the authority gradient so that staff are prepared to challenge their senior colleagues.
'Another strategy is threat and error management, which is about identifying and eliminating risks before they transpire. The example I always give is if you are wearing latex gloves, there's a chance that you could accidentally cause anaphylaxis in a patient with latex allergy - but by simply using latex-free gloves throughout the practice, you can't make that mistake.
'And there is a toolkit called local safety standards for invasive procedures (LocSSIPS) to prevent wrong site extraction in dentistry, which is available on the Faculty of Dental Surgery website. This is a sort of flowchart of steps that any dentist can do, such as pausing before starting the procedure to ensure you have the right site, confirming with the nurse and reflecting on how it went afterwards. Simple things like this don't cost anything, apart from maybe a couple of minutes of our time, but they can really reduce the number of errors.'
Recommending human factors tools and systems will be one aspect of the work of the NABHFD, along with initiatives in areas such as regulation, training, promoting the reporting of adverse incidents and near misses, and researching trends in the data. But all this work requires the support of the profession as a whole.
'100% of our successes and happy patients are down to our skills,' Simon reflects, 'but we also need to acknowledge that 80% of our complications are down to us too. Part of being a caring professional is wanting to improve and reduce these errors, and there is now a growing body of evidence that says addressing human factors is an effective way of doing that.'
Interview by Susan Field.
This fictitious case study highlights the issue and the practical steps that can improve patient safety.
A foundation dentist had been asked by the orthodontist treating a 14-year old girl to remove a retained lower right deciduous second molar (LRE). When the foundation dentist examined the patient, he incorrectly identified the lower right first permanent molar (LR6) as the tooth to be removed.
After administering local anaesthetic and checking for adequate analgesia, the dentist prepared to extract the tooth. Fortunately, the dental nurse was observing closely and intervened as the dentist was about to place the forceps on the lower right first permanent molar. She said to the dentist she did not think it was the correct tooth and pointed to the dental charting on the computer screen.
The dentist wisely paused the procedure, took stock, identified the correct tooth by checking it in the mouth against the referral letter from the orthodontist, the dental charting and radiographs, and double-checked it with the patient, the accompanying parent, and the dental nurse. Having satisfied himself that the correct tooth had now been positively identified, the LRE was removed uneventfully.
The foundation dentist subsequently discussed this human factors 'near miss' with his educational supervisor, and the nurse was praised for intervening and speaking up to avoid what would otherwise have been a serious adverse incident.
Had the wrong tooth been extracted, it would have had to be reported as a so-called 'never event' to the Care Quality Commission (CQC), there would have been a duty of candour obligation to inform the patient and accompanying parent immediately, and it would have been necessary to arrange the required remedial treatment in liaison with the orthodontist. There would also have been a risk of a subsequent formal complaint or claim for compensation on behalf of the patient.
A root cause analysis of the near miss was carried out by the foundation dentist and his educational supervisor, analysing what happened, how it happened and why it happened. There followed a discussion of the near miss at a practice meeting in an open, blame-free environment, and it was agreed that in the future the practice would adopt the Royal College of Surgeons dental LocSSIP tool aimed at preventing erroneous extractions.
To avoid adverse incidents and errors caused by human factors, it is very important to adopt a whole team approach and to overcome the so-called 'authority gradient', whereby any member of the dental team feels unable to intervene and speak up when they see a risk of avoidable harm to a patient.
It also important to involve the dental nurse, the patient and anybody else present in the surgery, such as a relative, in identifying the correct tooth or teeth to be treated, having cross-checked this against the records and radiographs before and after the patent enters the surgery. Lastly, if in doubt, the procedure should be postponed until any uncertainty has been satisfactorily resolved.
Rupert Hoppenbrouwers, senior dento-legal adviser, DDU