2021, Number 2
Applying of eight essential actions for patient safety in dentistry
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Language: English/Spanish [Versión en español]
References: 41
Page: 184-193
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ABSTRACT
Patient safety is a fundamental feature in primary health care services, including dentistry. Health systems around the world have promoted national programs to improve quality and patient safety, but dentistry area remains little studied. In Mexico, dentistry ranks fifth in complaints among all medical specialties and ranks first in complaints from private health services. Recently the regulatory authorities in health and educational health areas in Mexico (Consejo de Salubridad General and the Dirección General de Calidad y Educación en Salud) issued eight essential actions for patient safety, to be implemented in both hospital and outpatient areas. Dentistry is a profession that provides services in the outpatient setting, so those who dedicate themselves to it have the responsibility to comply with these actions. Nevertheless, there might be challenges to apply them in dental care establishments and services. This paper explores the importance and applicability of the 8 essential actions for patient safety in dentistry.INTRODUCTION
Dental surgeons are providers of oral and dental health care services. They are responsible of promoting healthy habits, preventing diseases as well as ensuring patient safety and quality of dental health care services.1,2 Since 2007, Mexico has recognized patient safety as a fundamental component of quality in health care services, which is currently reflected in the Plan Nacional de Desarrollo 2019-2024 (a national development plan)3 and in the Programa Sectorial de Salud 2020-2024 (a health sector program).4
Patient safety is considered a quality dimension.5 It is defined as the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum.6 In this context it is estimated that unintentional harm, known as an adverse event, occurs from 2 to 3% of the times that patients attend primary care service.7 Since 2002, the World Health Assembly –currently known as the World Health Organization (WHO) Patient Safety Program– has recognized adverse events as a public health problem.8 Unfortunately, most of the empirical evidence on patient safety has focused on hospital care.9
Patient safety in dentistry is a little explored areaDespite the fact that around eight billion primary care consultations are carried out each year in member countries of the Organization for Economic Cooperation and Development10 research on patient safety in primary care services still needs to be addressed5 particularly, to obtain information from developing countries,10 including Mexico. Consequently, patient safety in dentistry, being a primary care service, is also a little explored area.11 The available empirical evidence points to five main types of patient safety incidents (Table 1).11 Information available in Mexico indicates that dentistry is the fifth specialty with the highest demand for medical arbitration services, attended by CONAMED (the national body of medical arbitration) among all public, social and private health services.12 Triana-Estrada when analyzing 1,066 complaints reported to CONAMED from 2001 to 2011, found that private services represented the largest source (84.1%; n = 896).13 When analyzing complaints by specialty, prosthetics ranked first (30.0%), followed by general dentistry (20.0%), orthodontics (15.0%), prosthodontics (13.6%) and surgery (8.6%).10 A sub-analysis of 687 of these cases showed that 53% had evidence of malpractice and 47% of good practice.13
THE EIGHT ESSENTIAL ACTIONS FOR PATIENT SAFETY
In 2017 the Consejo de Salubridad General and the Dirección General de Calidad y Educación para la Salud issued the eight essential actions for patient safety14 (Table 2) which are applicable for inpatient and outpatient. In October 2017, the Diario Oficial de la Federación (the Official Journal of the Federation in Mexico) published these eight actions for their mandatory implementation in all health establishments of the national health system (Acuerdo CSG 60/06.03.17).15 It includes primary and outpatient care services, including both medical and dental. Although dental care services are also provided in the public sector, they are provided mostly in the private sector.16
Empirical evidence on patient safety in dentistry is scarce, so empirical evidence in medicine is often used as a benchmark. This is because it is currently the best available evidence. However, this evidence is representative of hospital medical services.9 Therefore, the processes and treatments are different than those provided on an outpatient basis. Consequently, the application of the eight essential actions for patient safety in dental services involves challenges. This paper offers an adaptation of them.
- 1. Patient identification. The purpose of this essential action is improving the patient identification accuracy by using at least two pieces of information to prevent errors involving a wrong patient.14 These two pieces of patient data should be verified before performing a clinical procedure, especially in case of surgical procedures. Examples of verifiable patient data are included in the medical record, including the patient's full name and date of birth. This action is one of the main features to be corroborated in the checklist for surgical procedures introduced by the WHO.17 This checklist has been adapted for dentistry such as third molar extraction,18 endodontic treatments,19 implant positioning20 as well as general dental procedures.21 This essential action can be implemented in dentistry. However, the main challenge is to modify the behavior of the dentists so that they systematically verify the identity of the patient, before a clinical procedure. Educational strategies are required to strengthen positive preclinical behaviors towards patient safety. Patient identification, including personal demographic information and the information about their health status and treatments must be correctly recorded in the medical record. This file must meet the characteristics required in numeral 5.5 of the NOM-004-SSA3-2012 (official standard in Mexico).22
- 2. Effective communication. This action aims improving communication between health professionals, patients and their family members, in order to obtain correct, timely and complete information during the care process.14 This action is in turn supported by article 41 of Ley General de Salud, which establishes that patients have the right to receive sufficient, clear, timely, and truthful information, as well as the necessary guidance regarding their health and about the procedural risks and alternatives, therapeutic and surgical diagnoses that are indicated or applied.2 One of the tools available to ensure effective communication between dentist and the patient is informed consent. This document provides the patient with individual protection of their autonomy, protection of the patient's condition as a human being, avoids fraud or decision-making under pressure, allows the dentist to consider their decisions with greater attention, motivates the patient to make rational decisions and promotes public participation in their treatment.23 In addition, obtaining informed consent is mandatory and must be included in the medical record. This is also stipulated in the NOM-004-SSA3-2012.22 The minimum requirements for informed consent are described in Table 3. The files must be updated periodically and any change in the treatment plan must also include informed consent. If there is communication with the patient electronically, orally or in writing, and the process of obtaining informed consent is not involved, it is recommended to use the Listen-Write-Read-Confirm process.14
- 3. Safety in medication process. Safe medication is the third global patient safety challenge promoted by WHO.24 Member countries, including Mexico, have made a commitment to reduce avoidable harm from medication. The Ley General de Salud, article 28 Bis, states that dental surgeons can prescribe medications.2 Therefore, dentists must strengthen actions related to the storage, prescription, transcription, dispensing and administration of medications, to prevent errors that could harm patients.14 In dentistry, unintentional damage derived from medication errors has focused on reporting the systemic consequences after the administration of local anesthesia, sedation and general anesthesia11 which include cardiovascular events (angina pectoris, myocardial infarction, etc.) allergic reactions and even death of the patient.11,25 Regarding the reported medication errors, these are related to medical prescription, such as the omission of therapeutic dose, the prescription of the wrong dose, typing errors and errors when specifying the duration of the treatment.26 Errors in medication process can lead to adverse reactions, including allergic reactions.27 In addition, overuse of incorrectly prescribed medications, or the lack of patient adherence to the treatment contribute in turn to resistance to antibiotics.28
- Resistance to antibiotics is estimated to be a problem for patient safety next decade.28 The strengthening of medication processes is an action that must be carried out in dental health establishments and services and any strategy to strengthen them must be based on articles 37 and 64 of the Ley General de Salud about the requirements of the medical prescription (Table 4).2
- 4. Safety in procedures. The purpose of this essential action is reinforcing safety practices internationally accepted and reducing adverse events to avoid sentinel events derived from surgical practice and high-risk procedures outside the operating room.14 A sentinel event refers to an unforeseen incident or event that results in death or serious physical or mental injury, or the risk of its occurrence.6 In dentistry the procedure that has received the most attention due to the potential risk of leading to severe damage is the erroneous surgical or non-surgical extraction of third molars.29 However, there are other surgical procedures in dentistry such as implant positioning, guided tissue regeneration, apicoectomies, among others. Dental treatments can also lead to adverse events with other local repercussions and in general with less severity of damage. These include abrasion injuries, thermal burns, chemical burns, as well as inhalation and/or ingestion of foreign objects.11,30 Finally, it is expected that dentist and auxiliary staff are properly trained in the management of complications in the dental office, such as cardiopulmonary arrest or allergic reactions. When consulting the Normative Appendix "B" of the Mexican Official NOM-005-SSA3-2010, which establishes the characteristics of a dental office equipment objects31 the "red (emergency) car" is not considered to attend an emergency. However, point 3.2 of the References Chapter of the Official Mexican Standard NOM-013-SSA2-2015 ("For the prevention and control of oral diseases") numeral 5.21, establishes that the stomatology office must have a first aid kit for medical emergencies.32
- Standardizing clinical procedures makes it possible to reduce their variation and to strengthen the quality and the consequent safety,33 which requires coordinated efforts by universities and educational institutions to strengthen and standardize clinical practices. However, the educational legislation for the training of human resources in dentistry is not clear. This has allowed the proliferation of schools whose graduates do not meet the quality standards and skills necessary to provide safe dental care for the population.34
- 5. Risk reduction of Healthcare-Associated Infections (HAI). This action aims to minimize HAI occurrence by implementing a comprehensive hand hygiene program during care process.14 In Mexico this action has been supported by the campaign "SAVE LIVES: wash your hands" introduced by WHO.35 However, reducing the risk of infections in the dental office is not limited to hand hygiene. In dentistry infection control is probably the most explored area with great professional interest and is included in NOM-013-SSA2-2015, numeral 5.10, which states that stomatology staff must master and practice infection control and patient safety in dental care area.32 Currently due to COVID-19 pandemic, infection control in a dental office has focused on triage and recording patient's temperature before a dental consultation, as well as hand washing and antisepsis, protective equipment staff, standard practices for surface disinfection and sterilization of instruments, as well as recommendations to minimize the production of aerosols and splashes.36,37.
- 6. Patient harm risk reduction due to falls. The purpose of this essential action is to prevent patient harm associated with falls in healthcare settings.14 In dentistry, the empirical evidence on patient falls in dental office has been previously reported.25 However, the frequency of this type of event and its risk of causing harm needs to be documented and reported in other studies to obtain an overview of the profession and to be able to formulate recommendations for its prevention. Therefore, patient falls in dental office should be considered as a type of incident to be recorded in incident and adverse event reporting systems developed for dentistry.
- 7. Recording and analysis of sentinel events, adverse events and near miss. This action aims generating information on near miss, adverse events and sentinel events, through a recording tool that allows analysis and favors decision-making to prevent their occurrence at local level.14 Incident and adverse event reporting systems provide information about the events leading to an adverse event.38 However, dentistry is a profession that is primarily practiced privately, so dentists generally have full administrative, financial, and clinical responsibilities for offices. Consequently, services provided in these establishments usually are the main source of income, so there is a general fear in the profession that providing information about their errors and adverse events will have negative financial or even legal repercussions as a result of a perception of poor quality of service by patients.39
- In Mexico it is recognized the importance of a learning model for quality in dentistry through the creation of an adverse event recording center.34 However, this should be non-punitive, confidential and / or anonymous, independent of any authority that can sanction the organization or the notifier; in addition, the information registered should be analyzed by staff trained in quality systems and patient safety.38 Any system for reporting incidents and adverse events must be supported by the Conceptual Framework for the International Classification of Patient Safety.6 In this way, in the analysis of reported events, incidents, near miss (incidents that do not reach the patient), adverse events (incidents that cause harm) and sentinel events can be identified.38 According to WHO a sentinel event is defined as any event that has resulted in an unanticipated patient death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition.6 Therefore, through the recording and monitoring of these events, priorities can be identified and recommendations for continuous improvement in dental care establishments and services can be issued.
- 8. Patient safety culture. Patient safety culture is the fundamental element in reduction of adverse events.40 It is defined as the product of individual and collective values, attitudes, perceptions, competencies and patterns of behavior that determine the commitment to health and safety management in the organization, as well as the style and competence of such management.6 The last essential action aims its measurement to favor decision-making for continuous improvement.14 In dentistry this area has also been little explored. For its dental use it is necessary to adapt the available tools in measuring patient safety culture in dental primary care.41
CONCLUSIONS
Patient safety in dentistry is an area that requires further development in terms of research and strategies for monitoring incidents and adverse events. At the moment, the eight essential actions for patient safety can be used mostly in dentistry. However, as the empirical evidence base in this profession increases, it will need to be updated. Meanwhile, improving patient safety requires the coordinated efforts of educational institutions and existing specialized dental associations. COVID-19 pandemic shows that patient safety is constantly evolving and it will need to be periodically evaluated to corroborate its coherence with social reality. Legislation and mechanisms for monitoring compliance with essential actions should support this task. In addition, patient safety is a discipline that requires leadership for an adequate promotion in the professional union.
REFERENCES
Comisión Nacional de Arbitraje Médico. Memoria de la 1a Reunión Regional sobre Solución de Controversias entre Usuarios y Prestadores de Servicios de Salud. [Internet]. [Consultado 5 abril 2021]. Disponible en: https://www.gob.mx/conamed/prensa/1a-reunion-regional-sobre-solucion-de-controversias-entre-usuarios-y-prestadores-de-servicios-de-salud
Secretaría de Gobernación. ACUERDO por el que se declara la obligatoriedad de la implementación, para todos los integrantes del Sistema Nacional de Salud, del documento denominado Acciones Esenciales para la Seguridad del Paciente. Diario Oficial de la Federación. [Internet]. [Consultado 5 abril 2021]. Disponible en: http://dof.gob.mx/nota_detalle.php?codigo=5496728&fecha=08/09/2017
Diario Oficial de la Federación. Norma Oficial Mexicana NOM-005-SSA3-2010, Que establece los requisitos mínimos de infraestructura y equipamiento de establecimientos para la atención médica de pacientes ambulatorios. [Internet]. [Consultado 5 abril 2021]. Disponible en: http://www.dof.gob.mx/normasOficiales/4132/Salud/Salud.htm
AFFILIATIONS
1 Doctorado en Salud Pública, Universidad de Edimburgo, Reino Unido. Jefe de Departamento de Investigación. Comisión Nacional de Arbitraje Médico. México.
2 Especialista en Odontología Pediátrica, Hospital Infantil de México "Federico Gómez", Profesor Investigador de la Universidad Autónoma Metropolitana-Xochimilco. México.
3 Especialista en Endoperiodontologi?a, Profesor Investigador de la Universidad Autónoma Metropolitana-Xochimilco. México.
4 Subcomisión Jurídica. Comisión Nacional de Arbitraje Médico. México.
5 Dirección General de Difusión e Investigación, Comisión Nacional de Arbitraje Médico. México.
6 Dirección de Investigación, Comisión Nacional de Arbitraje Médico. México.
Funding sources:None. Conflict of interest: The authors declare no conflict of interest.
CORRESPONDENCE
Dr. Eduardo Ensaldo-Carrasco. E-mail: eduardo.ensaldo@gmail.comReceived: Abril 2021. Accepted: Junio 2021.