This article from the British Association of Oral Surgeons (BAOS) highlights that these clinicians perform a high volume of multi-site complex procedures, on anxious patients who are frequently conscious, that have the potential for error to occur.
Wrong tooth extraction has been clearly designated as a 'never event' since April 2015. However, in 2016/17, wrong tooth extraction topped the charts as being the most frequently occurring never event based on NHS England’s data.
What can we do to mitigate these incidents?
Based on both practical experience and research evidence, BAOS advises that the main methods for mitigation of errors are:
- learning from mistakes – including investigation and root cause analysis
- engaging the clinical team when developing 'correct site surgery' policies
- utilising the LocSSIPs template and guidelines from NHS England/RCS England
- developing a correct site surgery checklist that is appropriate for your clinical environment
- providing training for staff on the use of the checklist
- ensuring that the checklist is being used correctly through active audits of the processes involved
- supporting the clinical team throughout the process and not taking punitive action when incidents do occur.