Wrong Tooth Removal, No Longer A ‘Never Event’
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- Published: Thursday, 25 February 2021 07:46
- Written by Chris Tapper
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Wrong site tooth extraction has been removed from NHS England’s list of Never Events.
In the latest revision of NHS Improvement’s Never Events list 2018, wrong site tooth extraction has been excluded from the ‘Wrong Site Surgery’ category.
In a press release, The Faculty of General Dental Practice UK (FGDP) has welcomed the change, which will come into effect on April 1st.
The FGDP release said ‘The NHS defines Never Events as incidents with “the potential to cause serious patient harm or death” that are “wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers.’
It went on “The amendment to the list was recommended by an interdisciplinary, multi-stakeholder working group convened by NHS Improvement, whose review found that the barriers available and in place to prevent occurrences of wrong site tooth extraction are insufficient to meet the Never Event definition.”
“The same recommendation has also been made by the Healthcare Safety Investigation Branch in its recently-published National Learning Report on investigations into Never Events, which details ten incident types across healthcare, including wrong site dental extraction, which it says do not meet the definition.”
“While this development means there are no longer any dentistry-specific mishaps classified as Never Events by the NHS, incidents of wrong site extraction are still classified as Patient Safety Incidents, and should continue to be reported, and managed, accordingly.
In the latest update from the England Chief Dental Officer, Sara Hurley said "The Never Events list has been updated and wrong tooth extraction should now be singularly reported as a patient safety incident. In my view, wrong tooth extraction is unacceptable and patients have every right to demand that every measure is taken to avoid it. It must never be normalised. But it is, sadly, not completely unavoidable. I am confident the patient safety incident arrangements both reflect the clinical situation on tooth extraction and respect the patient's right to protection from such an incident."
Former FGDP(UK) Dean, Mick Horton, represented the Faculty on NHS Improvement’s working group, and was also among those who developed the NHS Local Safety Standard for Invasive Procedures (LocSSIPs) toolkit, which is available on the FGDP website.
The former Dean commented “I’m delighted that NHS England has acted swiftly to accept the recommendation that wrong site extraction should no longer be classified as a Never Event. However it remains vitally important to report and manage any instances as Patient Safety Incidents, and I would urge dental teams and practice managers to download and digest the ‘LocSSIPs’ toolkit in order to minimise the risk of wrong site extraction happening in their practice.”
The ‘LocSSIPs’ toolkit is available at
https://www.fgdp.org.uk/sites/fgdp.org.uk/files/docs/news/2017/locssips%20toolkit%20dental%20extraction.pdf.
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