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Prevention of Wrong-Site Tooth Extraction: Clinical Guidelines

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Wrong-site tooth extraction can be defined as the extraction of a tooth other than the one intended by the referring dentist. This adverse event continues to be one of the major reasons for filing malpractice claims against oral and maxillofacial surgeons. Most cases of wrong-site tooth extractions are preventable and can be minimized by the development of an educational program, an informative, unambiguous referral form, a pre-operative check list, and incorporation of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery into daily clinical practice.
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... The remaining causes of tooth extraction were all operator related and ranged from being overworked to lacking experience. Miscommunication seems to be a common finding among several studies, [4,5,7] whether it be an internal communication issue or an external communication issue with the referring doctor or dentist. [4,7] The surprising part of this study was the attitude of respondents to an incident of wrong tooth extraction because most shied away from documenting the incident and from claiming responsibility and offering any kind of solution or compensation. ...
... Miscommunication seems to be a common finding among several studies, [4,5,7] whether it be an internal communication issue or an external communication issue with the referring doctor or dentist. [4,7] The surprising part of this study was the attitude of respondents to an incident of wrong tooth extraction because most shied away from documenting the incident and from claiming responsibility and offering any kind of solution or compensation. These results are slightly different from those of Adeyemo et al. ...
... According to Lee et al., if the wrong tooth has been extracted, it is the legal obligation of the operator to inform the patient immediately when the error has been identified and then advise the patient for an appropriate line of action. [7] We realize, however, that the low response rate of 37% in this study may limit its generalizability and that nonresponders may have different attitudes. We are also hopeful that future studies, perhaps of a different study design, will venture to further explore this problem. ...
Article
Background: Dental extraction is a common procedure that is subject to complications and errors including extraction of the wrong tooth. This study aimed to determine the prevalence and identify the causes of wrong tooth extractions and explore the attitude of dentists after extraction of a wrong tooth. Methods: A questionnaire was adapted to fit the needs of this project and was distributed among all the dentists in four teaching dental clinics. The questionnaire was available in both the English and Arabic languages. Results: Of the 486 questionnaires, 186 questionnaires were returned (response rate of 37%) and used for the analysis. The prevalence of wrong tooth extraction was 21.1%. The three most common reasons for extracting a wrong tooth were miscommunication (31.6%), inadequate referral (28.9%), and exhaustion of an overworked dentist (28.9%). Surprisingly, only 50% informed the patient and documented the incident in the patient's chart. Few dentists apologized to their patients or offered any kind of solution or compensation. Conclusion: Wrong tooth extraction is a prevalent yet preventable problem. Most of the common causes of this problem appear to be more system rather than individual related. There is a pressing need to implement the universal protocol for the prevention of wrong site, wrong procedure, and wrong person surgery.
... 11 Extraction of wrong tooth is a critical medical error that causes medico-legal problems. 13 Predictably, this high anxiety is caused by the awareness of dental students about the medical and legal implications that the clinician faces in case of wrong tooth extraction. Getting infected by the patient was seen as the second highest anxiety-provoking situation amongst the students that participated in the current study. ...
Article
Introduction: The aims of this study are to evaluate the situations that cause anxiety in clinical training and to discuss the precautions that can be taken to reduce clinical anxiety in dental education. Materials and methods: This multi-centered survey based study was created through Google Docs and 3rd, 4th and 5th grade dental students were included. The students were asked to rate their reactions on a 4-point Likert scale "not anxious" to "very anxious" for 27 questions related to academics, communication and interaction, diagnosis, dental treatments, deficiencies and mistakes in the treatments. Results: 1332 students were reached, and 1320 students completed the questionnaire. While extracting wrong tooth (3.53 ± 0.83), getting infected by patient (3.39 ± 0.85), getting diagnosis wrong (3.31 ± 0.83) were identified as the 3 most anxiety-provoking situations; taking panoramic radiograph (1.48 ± 0.71), communication with patients and dental assistants /nurses (1.76 ± 0.87; 1.64 ± 0.76) were identified as 3 situations that cause the least anxiety. Female students reported higher anxiety levels than male students in most of the questions (p<0.05). A statistically significant difference was observed between the grades of the students (p <0.05). 3rd grade students showed statistically higher anxiety levels than higher grades in 16 out of 27 questions. No statistical significance was observed according to the status of the university (p>0.05). Conclusion: Questions related to diagnosis, delivery of the dental treatments, deficiencies and mistakes in the treatments caused higher anxiety levels among dentistry students. As experience and time in the clinical training increase, the anxiety level of the students decreases. Orientation programs and establishing an effective communication between grades are recommended. Also, gender-based solutions must be taken into consideration.
... To prevent any source of miscommunication, ensure correct patient name, file number, diagnosis and investigations. These all should match and any uncertainty should elicit revising the diagnosis with the referring dentist and the patient [2]. In addition, evaluation allows for determining the difficulty of the procedure and the need for certain instruments or situations for example sedation or general anesthesia. ...
... This may be due to the fear of not being able to extract the retained tooth due to inability to get proper apical thrust grip by forceps or also not knowing the direction & amount of force to be applied to remove the fractured tooth and medico legal implications associated with extraction of wrong tooth. 17 Significantly higher anxiety among third year students was noted in communicating with patients, taking history, examining patients and making and presenting diagnosis to the instructor as compared to final year students. It might be because of transition and acquaintance with the new environment of dealing with the patients directly in the clinical setting. ...
... Similar results have been demonstrated in a previous study where dental extractions was rated as the most scariest procedure, as perceived by Pakistani dental students (Ali et al., 2015) Fracturing a tooth during extraction may happen because of inadequate apical thrust or it could be associated with lack of confidence to do proper extraction forces. The prevalence of extracting wrong teeth among dental students in Otago was reported to be 13% (Kieser and Herbison, 2000) and it is considered as a medical error with medico-legal complications (Lee, Curley and Smith, 2007). ...
... 25 Research conducted by Janice et al, and Lee et al also stated that presence of several notation system can lead to dental misconduct. 26,27 Likewise the disparity in maintaining dental records between different Dental departments within a hospital due to practice of different numbering system will have undesirable consequences as these dental records plays crucial role in serving as medicolegal reports and as forensic evidence. Lastly one of the major prerequisites of clinical audit is maintain uniformity in dental records keeping. ...
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OBJECTIVE: To identify the various types of dental notation system preferred by students working within the dental hospital and to evaluate the tooth notation methods favored by the different clinical departments in a dental teaching hospital of Karachi. METHODOLOGY: This Cross sectional study was conducted within the dental hospital of Bahria University Medical and Dental College. The survey employed for this study was modified from the study lead by Al-Johany SS. All the qualitative variables are presented as frequency and percentages. Chi-square or Fischer exact test was applied to see the significance P-value < 0.05 considered to be statistically significant. RESULTS: A total of 153 students participated in the study. FDI was commonly understandable tooth Numbering system by 66% (n= 48) of the final year students while 49% (n=39)of the house officers preferred Universal system. For coding primary teeth palmer system was identified, while for permanent dentition FDI was preferred. CONCLUSION: This study clearly highlights that different method for tooth numbering will be used continually by the dental professionals. Realistic approach is to make sure that dental professionals have sufficient knowledge regarding the most commonly used numbering systems and are responsive towards the pitfalls in each system. KEYWORDS: Notation, Tooth numbering system (TNS), FDI, Palmer, Universal system
... Although Fricton et al. described that the intervention did not work in a randomized control trial [13], one of the interventions to reduce incidents may be checklist. Some articles reported the effectiveness of checklists to mitigate incidents [14,15] while the other showed the opposite result [16]. Among various measures to reduce incidents, a systematic review have reported that only surgical safety checklists contributed to the reduction of AEs in dentistry [11]. ...
Article
Objectives Our objectives are to characterize the incidents in the department of oral and maxillofacial surgery (OMFS) in comparison with the whole hospital incidents including other dental specialty. Materials and methods We analysed 1185 cases during 5 years, which were collected from the database of the incident reporting system of Fukuoka Dental College Medical and Dental Hospital, and compared the frequencies, severity and causes of incidents between OMFS department and the whole hospital. Severity level of incident (level 0, 1, 2, 3a, 3b, 4 and 5) was classified according to the incident severity classification system recommended by the National University Hospital Council of Japan) (level 0 and 1; no patient harm; level 2 to 5; patient undergoing any harm). Results During 5 years, total 1185 cases of incidents were reported in the whole hospital while 155 cases (13%) of them occurred in the OMFS department. Many of severe incidents, level 3a and level 3b, occurred in the OMFS department rather than in the other dental specialties. Over sixty percent of the incident-related factors were due to the lack of confirmation, following immature skill. Incorrect order of X-ray, treatment-related injury, missing or fractured equipment, remaining of foreign body or tooth, ingesting of dental object frequently occurred. Conclusion For patient safety of dentistry, it is important to keep interdisciplinary communication before practice on patients. We must report our incidents without hesitation, which will lead to the improvement of dental quality.
Article
Purpose Medical malpractice claims contribute to the practice of defensive medicine which exposes patients to unnecessary tests and limits access to care. The purpose of this study is to characterize medical malpractice claims involving temporomandibular joint (TMJ) operations by oral and maxillofacial surgeons (OMS) in the United States. Materials and Methods Retrospective cross-sectional study of closed medical malpractice claims against OMS in the Unites States insured by OMS National Insurance Company, RRG (OMSNIC) from January 1, 2016, through December 31, 2020. All claims were obtained from the OMSNIC claims database and classified by procedure type. The primary outcome measure was closed claims involving a TMJ operation. Claims regarding post-operative TMJ complications from non-TMJ operations were excluded. Predictor variables included alleged error and type of TMJ procedure performed. Claim outcome was reported as a secondary outcome measure. Additional outcomes measured included claims involving dentoalveolar or dental implant procedures. Descriptive statistics performed, and risk ratios calculated for TMJ claim settlement by alleged error and procedure. Significance was set at P < 0.05. Results A total of 1455 closed claims occurred during the study period. There were 14 closed claims involving a TMJ operation (0.96% of all claims). “Improper performance” was the most common alleged error for TMJ claims. Two claims (1 TMJ arthroscopy and 1 TMJ replacement) were settled with payment and the alleged error for these claims was improper performance. No TMJ claim received a court adjudicated payout. Dentoalveolar and dental implant related claims made up 68.73% (n=1,000) and 15.53% (n=226) of all OMSNIC claims respectively. The risk of a settlement was not significantly influenced by alleged error or TMJ procedure performed. Conclusions Medical malpractice claims against OMS for TMJ operations are very uncommon. Medical malpractice risk should not factor into a surgeon’s decision to exclude TMJ operations from their practice.
Article
Statement of problem: Surgical safety checklists are commonly used in medical surgery to reduce errors, yet they are rarely used in the dental office. Presently, research on the implementation of surgical safety checklists in implant dentistry and user adherence is lacking. Purpose: The primary purpose of this quality assessment study was to evaluate user compliance by using a surgical safety checklist for dental implant surgeries in a postgraduate prosthodontics program at the University of Connecticut School of Dental Medicine. The secondary purpose was to identify and analyze the nature, number, and frequency of omitted items on the surgical safety checklist. Material and methods: All surgical safety checklists completed by 8 prosthodontic residents from 120 dental implant surgeries over the course of 1 academic year were collected as part of the program's quality assessment. Each surgical safety checklist contained 12 preoperative items and 14 postoperative items, giving a total of 26 items to be analyzed for each dental implant surgery. The collected data were then analyzed for user compliance, as well as the nature, number, and frequency of omitted items. Results: Surgical safety checklists from 120 dental implant surgeries encompassing 262 implants were accessed for the academic year cycle from July 2017 to June 2018. There were 6 additional dental implant surgeries whose checklists were inaccessible. There was a 100% compliance rate for surgical safety checklist completion by all 8 prosthodontic residents across 120 dental implant surgeries. Within the checklists, the rate of incomplete responses or omissions was 2.4% (n=77). The 5 most commonly omitted items on the checklist by residents were preoperative photographs (0.29%), postoperative analgesics or steroids (0.26%), preoperative oral antiseptic rinse (0.22%), postoperative prescriptions (0.19%), and signed prosthodontic treatment plan forms (0.16%). Conclusions: There was excellent compliance with the implemented dental implant surgical safety checklist across 8 prosthodontic residents, and the number of omitted items was small. Surgical safety checklists appear to be a straightforward method of helping prosthodontic residents in their dental implant surgical training to provide consistent and high-quality safe treatment for patients.
Chapter
If a dental practitioner performs surgery, he or she will have complications. This chapter will describe the evaluation and management of the most common surgical complications that might occur when performing dentoalveolar surgery.
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As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. We reviewed 30,121 randomly selected records from 51 randomly selected acute care, nonpsychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. Adverse events occurred in 3.7 percent of the hospitalizations (95 percent confidence interval, 3.2 to 4.2), and 27.6 percent of the adverse events were due to negligence (95 percent confidence interval, 22.5 to 32.6). Although 70.5 percent of the adverse events gave rise to disability lasting less than six months, 2.6 percent caused permanently disabling injuries and 13.6 percent led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test chi 2 = 21.04, P less than 0.0001). Using weighted totals, we estimated that among the 2,671,863 patients discharged from New York hospitals in 1984 there were 98,609 adverse events and 27,179 adverse events involving negligence. Rates of adverse events rose with age (P less than 0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (P less than 0.01). There were significant differences in rates of adverse events among categories of clinical specialties (P less than 0.0001), but no differences in the percentage due to negligence. There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.
Article
Objectives. The aim of the study was to investigate the effectiveness of an educational program on the reduction of the incidence of wrong-site tooth extraction at the outpatient department of a university hospital in Taiwan. Study design. Data collected from cases of wrong-site tooth extraction during 1996 to 1998 were used to develop a specific educational intervention that was implemented from 1999 to 2001. The annual incidence of erroneous extraction was compared between the preintervention and intervention periods. The factors contributing to wrong tooth extraction were also analyzed. Results. The annual incidence rates of erroneous extraction from 1996 to 1998 were 0.026%, 0.025%, and 0.046%, respectively. During the intervention period from 1999 to 2001, wrong-site tooth extraction did not occur at the department. There was a significant difference in the incidence of erroneous extraction between the preintervention and intervention periods (P<.01). Cognitive failure was the most frequent form of active failure responsible for wrong-site tooth extraction, whereas communication and training were found to be major latent factors contributing to these errors. Conclusions. Our results suggest the effectiveness of an educational program comprising case-based materials, information feedback, and clinical guidelines in reducing the incidence of wrong-site tooth extraction.
Article
Background: As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. Methods: We reviewed 30 121 randomly selected records from 51 randomly selected acute care, nonpsychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. Results: Adverse events occurred in 3.7% of the hospitalizations (95% confidence interval 3.2 to 4.2), and 27.6% of the adverse events were due to negligence (95% confidence interval 22.5 to 32.6). Although 70.5% of the adverse events gave rise to disability lasting less than 6 months, 2.6% caused permanently disabling injuries and 13.6% led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test chi(2) = 21.04, p<0.0001). Using weighted totals we estimated that among the 2 671 863 patients discharged from New York hospitals in 1984 there were 98 609 adverse events and 27 179 adverse events involving negligence. Rates of adverse events rose with age (p<0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (p<0.01). There were significant differences in rates of adverse events among categories of clinical specialties (p<0.0001), but no differences in the percentage due to negligence. Conclusions: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.
Article
Background: As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. Methods: We reviewed 30 121 randomly selected records from 51 randomly selected acute care, non-psychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. Results: Adverse events occurred in 3.7% of the hospitalizations (95% confidence interval 3.2 to 4.2), and 27.6% of the adverse events were due to negligence (95% confidence interval 22.5 to 32.6). Although 70.5% of the adverse events gave rise to disability lasting less than 6 months, 2.6% caused permanently disabling injuries and 13.6% led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test χ2 = 21.04, p<0.0001). Using weighted totals we estimated that among the 2 671 863 patients discharged from New York hospitals in 1984 there were 98 609 adverse events and 27 179 adverse events involving negligence. Rates of adverse events rose with age (p<0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (p<0.01). There were significant differences in rates of adverse events among categories of clinical specialties (p<0.0001), but no differences in the percentage due to negligence. Conclusions: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.
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Background: Mistakes are an inevitable part of the practice of medicine. While the frequency and severity of medical errors are documented, little is known about patients' attitudes toward physician mistakes. Objective: To examine patient attitudes about physician errors. Design: A survey instrument assessed attitudes to 3 levels of physician mistakes (minor, moderate, and severe) and 2 fundamental physician responses: disclosure or nondisclosure. One hundred forty-nine study subjects were randomly selected from an academic general internal medicine outpatient clinic. Results: Virtually all patients (98%) desired some acknowledgment of even minor errors. Patient's desire for referral to another physician ranged from 14% following a minor mistake to 65% following a severe mistake. For both moderate and severe mistakes, patients were significantly more likely to consider litigation if the physician did not disclose the error. In the moderate mistake scenario, 12% of patients would sue if informed by the physician vs 20% if the physician failed to disclose the error and they discovered it by some other means (P<.001). Conclusions: Patients desire an acknowledgment from their physicians of even minor errors, and doing so may actually reduce the risk of punitive actions. These findings reinforce the importance of open communication between patients and physicians.Arch Intern Med. 1996;156:2565-2569
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As can be seen from this report, multifactorial considerations are often present in an orthodontic case. Office policy considerations regarding interoffice communications should be reviewed periodically as to their sufficiency. Interpersonal communications are vitally important from both a risk management standpoint and also from the perspective of maintaining a good doctor-patient relationship. Practitioners today need to keep a wary eye open regarding all possible treatment alternatives, even bizarre ones, should the clinical situation dictate the need for them. Good recordkeeping and documentation are omnipotent should one have the need to defend one's actions. This applies not only to radiographs, photographs, and treatment charts but to records of third-party conversations as well. The doctrine of informed consent should act as a guideline to what information need be transmitted to the patient, both at the beginning and throughout treatment, as it can often help calm potentially troubled waters. Finally, a little luck never hurt anybody.