Just excuse me for a minute whilst I saddle up my hobby horse!

So where are we up to with patient safety in dentistry? Are we slavishly following checklists developed by people who do not understand the subtleties of dental care? Or are we actively involved in the concept of patient safety, realising that checklists are only part of the picture?

In my experience, the development of patient safety interventions in oral surgery has boiled down to culture change. How long does it take to change culture? It takes years. Think of the situations we work in, they are not straightforward and we are aware that errors can and do still occur. The revolving door of students and junior staff in hospitals makes this all the more difficult – the culture change is akin to painting the Forth bridge (although they found new paint for this and only have to do it every 25 years!).

I think that our profession needs to take ownership of this problem – why are we told by other healthcare professionals (who have never administered one) that a wrong side ID block is a ‘never event’? There has been some sensibility in this recently, with the wrong side ID block now clearly not designated as a ‘never event’1. At a recent high level trust meeting I attended on serious incidents, a wrong side ID block was discussed with the chair concluding ‘didn’t it just wear off?’ I believe that we are only beginning to understand the subtleties of patient safety in dentistry – why isn’t filling the wrong tooth or performing root canal treatment on the wrong tooth a ‘never event’? Or even erroneously irrigating a pocket with sodium hypochlorite in the belief that it was saline! Perhaps a dental never events framework is the way forward. I also don’t agree with the term ‘never event’ it is so negative and we know that they still do happen, so therefore it is etymologically incorrect! Perhaps they should be ‘always events’ – we always check we have the right patient, we always provide the correct treatment… Food for thought (I hope).


Edmund Bailey

BAOS Council Member