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Wrong tooth extraction: an examination of 'Never Event' data.

M N Pemberton¹, M P Ashley², A Saksena³

¹Consultant in Oral Medicine, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK.

The British Journal of Oral & Maxillofacial Surgery

|June 22, 2016

Summary

Wrong tooth removal is a common "never" event in England, accounting for up to 25% of wrong-site surgeries. Further investigation into reporting and prevention strategies for these dental never events is crucial.

Keywords:

Never events Patient safety Wrong tooth

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Area of Science:

Patient Safety
Surgical Adverse Events
Dental Surgery

Background:

The National Health Service (NHS) in England categorizes severe patient safety incidents, such as wrong-site surgery, as "never" events.
These events, though rare, have significant implications for patient care and healthcare system accountability.

Purpose of the Study:

To analyze the incidence and characteristics of "wrong tooth/teeth removed" events within the broader category of "never" events.
To determine the proportion of wrong-site surgery never events attributable to dental procedures.

Main Methods:

Review of published data on NHS "never" events in England.
Analysis of incident reports from April 2012 to October 2015.
Focus on "wrong site" events, specifically "wrong tooth/teeth removed" incidents.

Main Results:

"Wrong tooth/teeth removed" was identified as the most frequent "wrong site" never event.
These dental errors constituted 20%–25% of all wrong-site surgery never events.
They represented 6%–9% of all reported "never" events during the study period.

Conclusions:

"Wrong tooth/teeth removed" events are a significant subset of surgical never events, primarily reported by hospitals and Community Trusts.
There is a need to understand the recording mechanisms for these incidents.
Developing effective prevention strategies for wrong tooth removal is essential for improving patient safety in dental care.