Selina Alexander reports on a recent presentation she attended by Aubrey Craig, a Senior Dento-legal Adviser at MDDUS, on the human factors in Dentistry and how to manage risk.
Are there areas of your practice or your work set up that you can tweak or change to reduce your exposure to risk? In his presentation Aubrey Craig suggested ways practices can improve patient safety.
While we might feel that we are operating safely, it‘s always helpful to have the advice of someone who understands the consequences of things going wrong to help us mitigate risks where possible.
An interesting point Aubrey made was about what dentistry has learned from the aviation industry, with its handovers and checks. He stressed the importance of everyone in the practice taking patient safety seriously as there may even be areas of a practice’s patients’ experience that may need tweaking to reduce exposure to risk.
So, what is risk management? Aubrey explained that it’s understanding that if you do something to a patient you’ve done on 26,000 people before, then the outcome of the treatment is fairly predictable, and the risk is low. But at some point, something could happen that changes that risk. However, there are things that we can control that will lower our exposure to risk.
Over the years, practitioners get used to identifying, assessing, judging, mitigating and possibly transferring non-risk to somebody else. Everything you do and for every procedure you carry out, there’s an element of risk. But risk is different depending on what’s being done. An exam, scale and polish carries virtually no risk. Whereas an implant procedure carries greater risks.
Unfortunately, risk is not linear, so this is something clinicians need to appreciate when they’re trying to manage it. At any time during an appointment or on a patient’s journey, the risk can change. So, it’s not a straight line and we’re constantly trying to balance things.
Swiss Cheese Model
When understanding that everything has a risk, how can we mitigate risks? We do this by having multiple checks and balances in place. Professor Jim Reason’s Swiss cheese model is still a great example of how to understand risk management. The holes in the Swiss Cheese model are the opportunities for error which could arise. They represent risks. Having layers of cheese offers a means of defence. When the holes are aligned, that’s when an error slips through a series of defences. In a dental context, major adverse events could result where the outcome may be a serious patient safety incident.
If all the holes are lined up and the checks and balances aren’t in place, then unfortunately the hazard will become an accident. But if you have put in place multiple checks and balances such as the correct patient being checked in at reception, the correct patient coming through to your surgery, and then checking their medical history. Before you begin treatment, confirming what you’re doing, getting your consent and then recording it. After the treatment, making sure they are given aftercare instructions, and the discharge procedure is followed, then there should be few, if any incidents.
So, what are the main risk factors? The four main ones are management systems, equipment and facilities, the environment and the treatment you are going to carry out. The environment relates to how your practice is structured, whether you have all the things you need to be able to do your job, how your surgery is set up and the types of treatment you provide. Although there are risks in all of these areas, they can be managed.
Overhaul Procedures
So, what have we learned from the aviation industry? In 1977, the airline industry saw its worst disaster when two aircraft collided on the runway of Tenerife airport and 583 passengers and crew lost their lives. The pilot of a KLM plane misunderstood the instructions he was given by air traffic control and believed he was clear to take off. However, a Pan Am airplane was still on the runway and the two collided.
Following an investigation into the crash the airline industry introduced a number of operational and procedural changes to improve safety and reduce the likelihood of a similar incident happening again. Radio phraseology was standardised to prevent misunderstandings, cockpit procedures were reviewed, and a culture established where the whole crew is involved in ensuring the aircraft’s safety, not just the captain.
This attitude towards safety can be employed in a practice. It takes the whole team to play a part in ensuring patient safety and shouldn’t just be left to the dentist alone. Although the investigation into the airline disaster did attribute blame its main purpose was to improve safety and prevent any such disaster from happening again.
No Blame
This is where a ‘no blame’ culture in your practice can help improve risk management. If you’re able to step away from finding someone to blame for a mistake and simply look at what went wrong, rather than who was the cause of the error, you are more likely to be able to get to the bottom of things. People will feel less inclined to try to cover up their mistakes if they feel they will not be punished for them and the true flaws in your systems are more likely to be uncovered.
Returning to the aviation industry, checklists help. Even though things may be routine, they make sure things aren’t missed. They also reassure the patient too. Poor communication was at the heart of the Pan Am/KLM disaster and checklists aid clear communication. Checking with each other, and with the patient, help ensure everyone understands what’s expected. It’s also important to keep good records of what’s been done.
A culture where the captain was infallible, was outlawed after the Tenerife disaster. Safety became the responsibility of every crew member and each one of them was given the authority to flag up an issue if they saw it. In a dental practice, if a nurse sees that the dentist is about to make an error, they should have the authority, and feel confident, to be able to issue a subtle warning to avert disaster. Colleagues and teamwork play important roles in plugging the holes in the Swiss Cheese.
If, despite all your best attempts to mitigate risk something does go wrong, then it’s important to be honest with the patient. Explain what’s happened, discuss what can be done to rectify it and apologise sincerely. A genuine apology goes a long way with many people, especially if they have a good rapport with the dentist. However, if an apology isn’t enough and the patient wants to take things further, then Dental Defence Unions are there to help and advise.
