How Dental Team Members describe Adverse Events
Identifieur interne : 002681 ( Pmc/Curation ); précédent : 002680; suivant : 002682How Dental Team Members describe Adverse Events
Auteurs : Peter Maramaldi [États-Unis] ; Muhammad F. Walji [États-Unis] ; Joel White [États-Unis] ; Jini Etoulu [États-Unis] ; Maria Kahn [États-Unis] ; Ram Vaderhobli [États-Unis] ; Japneet Kwatra [États-Unis] ; Veronique F. Delattre [États-Unis] ; Nutan B. Hebballi [États-Unis] ; Denice Stewart [États-Unis] ; Karla Kent [États-Unis] ; Alfa Yansane [États-Unis] ; Rachel B. Ramoni [États-Unis] ; Elsbeth Kalenderian [États-Unis]Source :
- Journal of the American Dental Association (1939) [ 0002-8177 ] ; 2016.
Abstract
There is increased recognition that patients suffer adverse events (AEs) or harm caused by treatments in dentistry, and little is known about how dental providers describe these events. Understanding how providers view AEs is essential to building a safer environment in dental practice.
Dental providers and domain experts were interviewed through focus groups and in-depth interviews and asked to identify the types of AEs that may occur in dental settings.
The first order listing of the interview and focus group findings yielded 1,514 items that included both causes and AEs. 632 causes were coded into one of the eight categories of the Eindhoven classification. 882 AEs were coded into 12 categories of a newly developed dental AE classification. Inter-rater reliability was moderate among coders. The list was reanalyzed and duplicate items were removed leaving a total of 747 unique AEs and 540 causes. The most frequently identified AE types were “Aspiration/ingestion” at 14% (n=142), “Wrong-site, wrong-procedure, wrong-patient errors” at 13%, “Hard tissue damage” at 13%, and “Soft tissue damage” at 12%.
Dental providers identified a large and diverse list of AEs. These events ranged from “death due to cardiac arrest” to “jaw fatigue from lengthy procedures”.
Identifying threats to patient safety is a key element of improving dental patient safety. An inventory of dental AEs underpins efforts to track, prevent, and mitigate these events.
Url:
DOI: 10.1016/j.adaj.2016.04.015
PubMed: 27269376
PubMed Central: 5045777
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<author><name sortKey="Delattre, Veronique F" sort="Delattre, Veronique F" uniqKey="Delattre V" first="Veronique F." last="Delattre">Veronique F. Delattre</name>
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<author><name sortKey="Hebballi, Nutan B" sort="Hebballi, Nutan B" uniqKey="Hebballi N" first="Nutan B." last="Hebballi">Nutan B. Hebballi</name>
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<country xml:lang="fr">États-Unis</country>
<wicri:regionArea>University of Texas Health Science Center, School of Dentistry at Houston, Houston, TX</wicri:regionArea>
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<author><name sortKey="Stewart, Denice" sort="Stewart, Denice" uniqKey="Stewart D" first="Denice" last="Stewart">Denice Stewart</name>
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<author><name sortKey="Kent, Karla" sort="Kent, Karla" uniqKey="Kent K" first="Karla" last="Kent">Karla Kent</name>
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<author><name sortKey="Yansane, Alfa" sort="Yansane, Alfa" uniqKey="Yansane A" first="Alfa" last="Yansane">Alfa Yansane</name>
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<wicri:regionArea>Harvard School of Dental Medicine, Boston, MA</wicri:regionArea>
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<author><name sortKey="Ramoni, Rachel B" sort="Ramoni, Rachel B" uniqKey="Ramoni R" first="Rachel B." last="Ramoni">Rachel B. Ramoni</name>
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<wicri:regionArea>Center for Biomedical Informatics, Harvard Medical School, Boston, MA</wicri:regionArea>
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<author><name sortKey="Kalenderian, Elsbeth" sort="Kalenderian, Elsbeth" uniqKey="Kalenderian E" first="Elsbeth" last="Kalenderian">Elsbeth Kalenderian</name>
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<wicri:regionArea>Harvard School of Dental Medicine, Boston, MA</wicri:regionArea>
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<series><title level="j">Journal of the American Dental Association (1939)</title>
<idno type="ISSN">0002-8177</idno>
<idno type="eISSN">1943-4723</idno>
<imprint><date when="2016">2016</date>
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<front><div type="abstract" xml:lang="en"><sec id="S1"><title>Background</title>
<p id="P2">There is increased recognition that patients suffer adverse events (AEs) or harm caused by treatments in dentistry, and little is known about how dental providers describe these events. Understanding how providers view AEs is essential to building a safer environment in dental practice.</p>
</sec>
<sec id="S2"><title>Methods</title>
<p id="P3">Dental providers and domain experts were interviewed through focus groups and in-depth interviews and asked to identify the types of AEs that may occur in dental settings.</p>
</sec>
<sec id="S3"><title>Results</title>
<p id="P4">The first order listing of the interview and focus group findings yielded 1,514 items that included both causes and AEs. 632 causes were coded into one of the eight categories of the Eindhoven classification. 882 AEs were coded into 12 categories of a newly developed dental AE classification. Inter-rater reliability was moderate among coders. The list was reanalyzed and duplicate items were removed leaving a total of 747 unique AEs and 540 causes. The most frequently identified AE types were “Aspiration/ingestion” at 14% (n=142), “Wrong-site, wrong-procedure, wrong-patient errors” at 13%, “Hard tissue damage” at 13%, and “Soft tissue damage” at 12%.</p>
</sec>
<sec id="S4"><title>Conclusions</title>
<p id="P5">Dental providers identified a large and diverse list of AEs. These events ranged from “death due to cardiac arrest” to “jaw fatigue from lengthy procedures”.</p>
</sec>
<sec id="S5"><title>Practical Implications</title>
<p id="P6">Identifying threats to patient safety is a key element of improving dental patient safety. An inventory of dental AEs underpins efforts to track, prevent, and mitigate these events.</p>
</sec>
</div>
</front>
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<front><journal-meta><journal-id journal-id-type="nlm-journal-id">7503060</journal-id>
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<journal-id journal-id-type="nlm-ta">J Am Dent Assoc</journal-id>
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<article-id pub-id-type="manuscript">NIHMS783071</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Article</subject>
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<title-group><article-title>How Dental Team Members describe Adverse Events</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Maramaldi</surname>
<given-names>Peter</given-names>
</name>
<degrees>PhD, MPH, LCSW</degrees>
<xref ref-type="aff" rid="A1">1</xref>
<xref ref-type="author-notes" rid="FN1">*</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Walji</surname>
<given-names>Muhammad F.</given-names>
</name>
<degrees>PhD</degrees>
<xref ref-type="aff" rid="A2">2</xref>
<xref ref-type="author-notes" rid="FN1">*</xref>
</contrib>
<contrib contrib-type="author"><name><surname>White</surname>
<given-names>Joel</given-names>
</name>
<degrees>DDS, MS</degrees>
<xref ref-type="aff" rid="A3">3</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Etoulu</surname>
<given-names>Jini</given-names>
</name>
<degrees>DDS, MPH</degrees>
<xref ref-type="aff" rid="A4">4</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Kahn</surname>
<given-names>Maria</given-names>
</name>
<degrees>DDS</degrees>
<xref ref-type="aff" rid="A4">4</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Vaderhobli</surname>
<given-names>Ram</given-names>
</name>
<degrees>DDS, MS</degrees>
<xref ref-type="aff" rid="A3">3</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Kwatra</surname>
<given-names>Japneet</given-names>
</name>
<degrees>BDS, MS</degrees>
<xref ref-type="aff" rid="A4">4</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Delattre</surname>
<given-names>Veronique F.</given-names>
</name>
<degrees>DDS</degrees>
<xref ref-type="aff" rid="A2">2</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Hebballi</surname>
<given-names>Nutan B.</given-names>
</name>
<degrees>BDS, MPH, PMP</degrees>
<xref ref-type="aff" rid="A2">2</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Stewart</surname>
<given-names>Denice</given-names>
</name>
<degrees>DDS, MHSA</degrees>
<xref ref-type="aff" rid="A5">5</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Kent</surname>
<given-names>Karla</given-names>
</name>
<degrees>PhD</degrees>
<xref ref-type="aff" rid="A5">5</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Yansane</surname>
<given-names>Alfa</given-names>
</name>
<degrees>PhD</degrees>
<xref ref-type="aff" rid="A4">4</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Ramoni</surname>
<given-names>Rachel B.</given-names>
</name>
<degrees>DMD, ScD</degrees>
<xref ref-type="aff" rid="A6">6</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Kalenderian</surname>
<given-names>Elsbeth</given-names>
</name>
<degrees>DDS, MPH, PhD</degrees>
<xref ref-type="aff" rid="A4">4</xref>
</contrib>
</contrib-group>
<aff id="A1"><label>1</label>
Simmons School of Social Work, Boston, MA</aff>
<aff id="A2"><label>2</label>
University of Texas Health Science Center, School of Dentistry at Houston, Houston, TX, USA</aff>
<aff id="A3"><label>3</label>
School of Dentistry, University of California, San Francisco, CA, USA</aff>
<aff id="A4"><label>4</label>
Harvard School of Dental Medicine, Boston, MA, USA</aff>
<aff id="A5"><label>5</label>
Oregon Health & Science University, School of Dentistry, Portland, OR, USA</aff>
<aff id="A6"><label>6</label>
Center for Biomedical Informatics, Harvard Medical School, Boston, MA, USA</aff>
<author-notes><corresp id="cor1">Corresponding author: Elsbeth Kalenderian, DDS, MPH, PhD, Chair, Oral Health Policy & Epidemiology and Chief of Quality, Harvard Dental Center, Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115, Tel: 617-432-1455 Fax: 617-432-0047, <email>Elsbeth_kalenderian@hsdm.harvard.edu</email>
</corresp>
<fn id="FN1"><label>*</label>
<p id="P1">Shared first authors</p>
</fn>
</author-notes>
<pub-date pub-type="nihms-submitted"><day>8</day>
<month>5</month>
<year>2016</year>
</pub-date>
<pub-date pub-type="epub"><day>03</day>
<month>6</month>
<year>2016</year>
</pub-date>
<pub-date pub-type="ppub"><month>10</month>
<year>2016</year>
</pub-date>
<pub-date pub-type="pmc-release"><day>01</day>
<month>10</month>
<year>2017</year>
</pub-date>
<volume>147</volume>
<issue>10</issue>
<fpage>803</fpage>
<lpage>811</lpage>
<pmc-comment>elocation-id from pubmed: 10.1016/j.adaj.2016.04.015</pmc-comment>
<abstract><sec id="S1"><title>Background</title>
<p id="P2">There is increased recognition that patients suffer adverse events (AEs) or harm caused by treatments in dentistry, and little is known about how dental providers describe these events. Understanding how providers view AEs is essential to building a safer environment in dental practice.</p>
</sec>
<sec id="S2"><title>Methods</title>
<p id="P3">Dental providers and domain experts were interviewed through focus groups and in-depth interviews and asked to identify the types of AEs that may occur in dental settings.</p>
</sec>
<sec id="S3"><title>Results</title>
<p id="P4">The first order listing of the interview and focus group findings yielded 1,514 items that included both causes and AEs. 632 causes were coded into one of the eight categories of the Eindhoven classification. 882 AEs were coded into 12 categories of a newly developed dental AE classification. Inter-rater reliability was moderate among coders. The list was reanalyzed and duplicate items were removed leaving a total of 747 unique AEs and 540 causes. The most frequently identified AE types were “Aspiration/ingestion” at 14% (n=142), “Wrong-site, wrong-procedure, wrong-patient errors” at 13%, “Hard tissue damage” at 13%, and “Soft tissue damage” at 12%.</p>
</sec>
<sec id="S4"><title>Conclusions</title>
<p id="P5">Dental providers identified a large and diverse list of AEs. These events ranged from “death due to cardiac arrest” to “jaw fatigue from lengthy procedures”.</p>
</sec>
<sec id="S5"><title>Practical Implications</title>
<p id="P6">Identifying threats to patient safety is a key element of improving dental patient safety. An inventory of dental AEs underpins efforts to track, prevent, and mitigate these events.</p>
</sec>
</abstract>
<kwd-group><kwd>Adverse event</kwd>
<kwd>Dentistry</kwd>
<kwd>Never event</kwd>
<kwd>Cause</kwd>
<kwd>Classification</kwd>
</kwd-group>
</article-meta>
</front>
</pmc>
</record>
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