Patient safety incidents in primary care dentistry in England and Wales: a mixed-methods study

Background: In recent decades, there has been considerable international attention aimed at improving the safety of hospital care, and more recently, this attention has broadened to include primary medical care. In contrast, the safety profile of primary care dentistry remains poorly characterized. Objectives: We aimed to describe the types of primary care dental patient safety incidents reported within a national incident reporting database and understand their contributory factors and consequences. Methods: We undertook a cross-sectional mixed-methods study, which involved analysis of a weighted randomized sample of the most severe incident reports from primary care dentistry submitted to England and Wales’ National Reporting and Learning System. Drawing on a conceptual literature-derived model of patient safety threats that we previously developed, we developed coding frameworks to describe and conduct thematic analysis of free text incident reports and determine the relationship between incident types, contributory factors, and outcomes. Results: Of 2000 reports sampled, 1456 were eligible for analysis. Sixty types of incidents were identified and organized across preoperative (40.3%, n = 587), intraoperative (56.1%, n = 817), and postoperative (3.6%, n = 52) stages. The main sources of unsafe care were delays in treatment (344/1456, 23.6%), procedural errors (excluding wrong-tooth extraction) (227/1456; 15.6%), medication-related adverse incidents (161/1456, 11.1%), equipment failure (90/1456, 6.2%) and x-ray related errors (87/1456, 6.0%). Of all incidents that resulted in a harmful outcome (n = 77, 5.3%), more than half were due to wrong tooth extractions (37/77, 48.1%) mainly resulting from distraction of the dentist. As a result of this type of incident, 34 of the 37 patients (91.9%) examined required further unnecessary procedures. Conclusions: Flaws in administrative processes need improvement because they are the main cause for patients experiencing delays in receiving treatment. Checklists and standardization of clinical procedures have the potential to reduce procedural errors and avoid overuse of services. Wrong-tooth extractions should be addressed through focused research initiatives and encouraging policy development to mandate learning from serious dental errors like never events.