Patient safety in dentistry – a decade in the making

For patient safety initiatives to be effective, it is essential that the appropriate culture is prevalent in the clinical setting. A positive or generative patient safety culture is one where safety is prioritised, resourced and practised by the team and its leaders. Table 2 summarises these qualities and behaviours in relation to a dental practice setting.

The NHS England ‘Patient safety strategy’ was published in 2019.¹⁸ The strategy encourages an engaged, visible leadership, promoting openness, just culture and continuous improvement, valuing diversity and equality. The document states that in a positive patient safety culture, safe care is delivered through:

• ‘Continuous learning and improvement of safety risks

• Supportive, psychologically safe teamwork

• Enabling and empowering speaking up by all’.¹⁸

The NHS England ‘Just culture guide’ can be used by employers where there is suspicion that an incident occurred due to the potentially negligent actions of an individual who will then require specific support or interventions to enable them to work safely. This may include involving regulatory bodies. This will rarely be required; however, reasonable consideration of this aspect of safety needs to be part of any healthcare system with a positive safety culture.

Work on improving patient safety culture has been carried out using a Safety II approach. The team looked at organisations which were identified by the Care Quality Commission as being rated as ‘good’ or ‘outstanding’ for ‘safe’ and then looked at what their good practices were.

Psychological safety involves:

• Civility – making personal connections with team members

• Creating a leadership promise and behaviour framework that staff can sign up to

• Appreciation of team members and granting them the permission and freedom to innovate.

Patient safety culture in dentistry appears to lag compared to medical specialties, especially in general dental practice. This may be due to several reasons:²⁹

• Dentistry is lower risk than medicine/surgery

• The outpatient nature of dentistry makes following-up on complications and care-related issues challenging

• Data collection can be difficult due to variations in dental care records

• Around 90% of dental care is carried out in dental practices which are run as businesses and reporting of harms may have a commercial/financial impact.

There are very few publications on patient safety culture in dentistry, and those that are published tend to focus on secondary care dental settings.^6,30 However, there is qualitative evidence that dental teams have high levels of knowledge and experience in maintaining patient safety.^31,32,33

Building a patient safety culture in dentistry:

• Encourages an open culture where all members of the team feel empowered to speak up on issues

• Brings safety to the agenda during meetings

• Encourages incident reporting, even for incidents considered to be low harm or near misses

• Investigates safety incidents using a transparent process

• Learns from these investigations and adopts a ‘just culture’ and supportive processes for managing those involved

• Provides training for the team on patient safety and non-technical skills for surgeons

• Moves from a reactive culture to a proactive one, where systems are designed with safety in mind, rather than waiting for incidents to occur and reacting to these.

When incidents do occur, the incident has an impact on the patient and their family primarily; these are the first victims. The clinician or clinical team involved in the incident can suffer psychological harm because of the incident and are termed second victims.³⁴ The ‘second victim’ concept has caused some controversy in the literature. While it is important to support healthcare workers who are involved in safety incidents, using the term ‘victim’ suggests no responsibility for the incident, and no accountability in dealing with the consequences. Being a ‘victim’ also suggests passiveness and lack of agency. For these reasons, some patients and their families avoid the use of the word ‘victim’ in relation to their own experiences of safety incidents.³⁵

A six-stage cycle is described that occurs in the aftermath of an event (Fig. 4).

The six-stage cycle that occurs in the aftermath of an event

Emotional and psychological support can help second victims to progress through this cycle more rapidly.^36,37 Some of the behaviours observed in those who are second victims include:³⁸

• Hypervigilance Stress Anxiety Shame

• Feelings of inadequacy

• Risk avoidance

• Self-doubt about knowledge and skills

• Insomnia

• Difficulty concentrating.

Furthermore, the impact on clinicians, especially in training, can be immense. It can also increase the risk of future incidents if not properly managed. This can lead to underperformance and depression, leading to a detrimental effect on patient safety. Early intervention and support are recommended to minimise the long-term sequela.

The Patient Safety Incident Response Framework (PSIRF) was rolled out during 2023-2024 and is a contractual requirement for NHS trusts. Primary care settings may wish to adopt PSIRF; however, it is not mandatory. This new framework includes a focus on engaging with everyone affected by patient safety incidents, and a document titled ‘Engaging and involving patients, families and staff following a patient safety incident’ is being developed. The process for reporting incidents is now known as ‘learn from patient safety events’ (LFPSE). Datix and similar incident report systems now feed into this. These efforts are part of a culture change away from the previous ‘blame culture’ into a more supportive culture which has been observed in healthcare settings.

Unfortunately, in dentistry, a culture of fear seems to prevail in terms of incident reporting and the perceived punitive consequences, which may include litigation and regulatory action associated with being involved in an incident.^6,31 This has also been highlighted as a problem with medical doctors, who are often reluctant to report incidents.³⁹ These are aspects of the ‘punishment myth’ – the idea that if we punish people when they make errors, they will not make them again.

We hope that the adoption of the NHS England ‘Just culture guide’ may help with managing those involved in safety incidents in a more supportive fashion while still highlighting areas of malpractice which do require intervention from an employer or regulatory body.

The 2019 NHS England ‘Patient safety strategy’ has recently been supplemented by the ‘Primary care patient safety strategy’, which was launched in September 2024. This strategy specifically mentions primary dental care. Among the aims of the strategy are:

• To provide access to the National Care Records Service for dentists in primary care. This provides the summary care record (current diagnoses, medications and allergies) and other important health-related information, such as child protection information, reasonable adjustments, mental health plans, transfer of care plans and end-of-life care plans

• To allow access to dental teams to the LFPSE national reporting system for incident reports

• To identify patient safety themes in dentistry and develop and test novel approaches for improvement and sharing of good practice

• Dental staff to complete local staff surveys, with action taken on the findings of these.

Allowing dentists to access the National Care Records Service will be a progressive step towards maintaining and improving patient safety and quality of care.⁴⁰ Relying on patient-declared medical histories before treating patients is fraught with problems. Patients often present to dental practices with several comorbidities and polypharmacy, and a proportion of patients will not fully recall their medical and drug histories.⁴¹ This can be more of an issue with certain vulnerable groups, including those with dementia and those with English as a second language. It can also be an issue when seeing emergency patients where no prior records are available. When dentists are provided with this information from the National Care Records Service, there may be a reduction of referrals to secondary care, as the practitioner will be more confident to manage the patient when they are fully informed of their medical history.

Project Sphere is a recent initiative by NHS England and the Office of the Chief Dental Officer. This project is specifically referenced in the ‘Primary care patient safety strategy’. The project aims to develop safety initiatives in dentistry and to deal with the blame culture which is so often cited. In June 2023, the group published huddle sheets, which have already been discussed.