A Two-Pronged Approach to Understanding Quality and Safety Events at the Dental Office

ABSTRACT Objectives: Owing to the limited number and scope of studies in dentistry regarding quality and patient safety, the overarching goal of this thesis was to understand the nature and occurrence of quality and safety events in dentistry using a two-pronged approach – biomedical literature and patient-reported experiences. Methods: I conducted two exploratory studies: the first was a detailed retrospective review of published case reports on dental patient safety events; the second was a cross-sectional study of 450 patients at a large dental teaching practice in South Africa about their quality and safety experiences using a self-adminstered questionnaire. Results: 180 case reports (270 cases) were identified through the literature search. Most reports came from Europe and North America. The most commonly-reported safety event was wrong treatment or unnecessary treatment following misdiagnosis (23%). 11% of case reports ended in the death of the patient. On the other hand, the patient survey revealed that 45.5% had experienced one or more safety events during dental visits in South Africa (1.6 events per respondent). Intra-oral hard tissue injury, such as adjacent tooth damage during treatment, was the most commonly reported event by patients (30.4%). ‘Never events’ such as wrong tooth extractions or wrong-site procedures, occurred in 7% of patients. The combined quality rating was fair; about 41.4% of participants rated the quality of dental care they received as sub-optimal. Access to care was ranked the lowest among patient-defined quality dimensions. Conclusions: Quality and safety events occur in dentistry, and are quite common. Published case reports offer a window into the types and severity of quality and safety events in dentistry. Although the literature is very skewed to reports of significant events and is thus not representative of all AEs that happen, it is a valuable source of information especially in the absence of a centralized reporting system. Patient reports much better let us understand the effects and sequelae of AEs. More work is needed to move the profession forward in our understanding of these events so that we may prevent them

Caries risk documentation and prevention : eMeasures for dental electronic health records

BACKGROUND: Longitudinal patient level dataavailable in the electronic health record (EHR)allows for the development, implementation, and validations of dental quality measures (eMeasures). Objective We report the feasibility and validity of implementing two eMeasures. The eMeasures determined the proportion of patients receiving a caries risk assessment (eCRA) and corresponding appropriate risk-based preventative treatments for patients at elevated risk of caries (appropriateness of care [eAoC]) in two academic institutions and one accountable care organization, in the 2019 reporting year. METHODS: Both eMeasures define the numerator and denominator beginning at the patient level, populations’ specifications, and validated the automated queries. For eCRA, patients who completed a comprehensive or periodic oral evaluation formed the denominator, and patients of any age who received a CRA formed the numerator. The eAoC evaluated the proportion of patients at elevated caries risk who received the corresponding appropriate risk-based preventative treatments. RESULTS: EHR automated queries identified in three sites 269,536 patients who met the inclusion criteria for receiving a CRA. The overall proportion of patients who received a CRA was 94.4% (eCRA). In eAoC, patients at elevated caries risk levels (moderate, high, or extreme) received fluoride preventive treatment ranging from 56 to 93.8%. For patients at high and extreme risk, antimicrobials were prescribed more frequently site 3 (80.6%) than sites 2 (16.7%) and 1 (2.9%). CONCLUSION: Patient-level data available in the EHRs can be used to implement process-ofcare dental eCRA and AoC, eAoC measures identify gaps in clinical practice. EHR-based measures can be useful in improving delivery of evidence-based preventative treatments to reduce risk, prevent tooth decay, and improve oral health.U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research.http://www.thieme.com/books-main/clinical-informatics/product/4433-aci-applied-clinical-informaticsDental Management Science

Dental public health post-graduate trainees in the US: Experiences, challenges, and opportunities-A qualitative study.

OBJECTIVES: The goal of this study was to explore challenges and opportunities that dental public health (DPH) residents and recent graduates experienced during and after their residency training programs in the US. METHODS: In this qualitative study, to recruit participants, study invitations were distributed to 93 DPH postgraduate trainees via social media, email, and an online DPH nationwide course in 2019. Semi-structured in-depth interviews were conducted through Zoom audioconference. The interviews were conducted until thematic saturation was achieved. The audio-recorded interviews were transcribed and crosschecked to ensure accuracy. The interviews were coded using grounded theory. A qualitative analysis software (ATLAS.ti 8.0) was used to facilitate coding and organizing data extraction from transcripts. RESULTS: Eighteen DPH postgraduate trainees from 12 DPH residency programs participated and completed the interview. DPH trainees had experienced educational and financial challenges, difficulty finding DPH-related jobs after graduation, and a complex board examination preparation process. CONCLUSION: DPH postgraduate trainees and especially foreign-trained dentists experienced serious challenges during and after their postgraduate residency programs. Opportunities exist to enhance the strength of DPH programs to build a competent DPH workforce

Patients’ Experiences of Dental Diagnostic Failures: A Qualitative Study Using Social Media

ObjectiveDespite the many advancements made in patient safety over the past decade, combating diagnostic errors (DEs) remains a crucial, yet understudied initiative toward improvement. This study sought to understand the perception of dental patients who have experienced a dental diagnostic failure (DDF) and to identify patient-centered strategies to help reduce future occurrences of DDF.MethodsThrough social media recruitment, we conducted a screening survey, initial assessment, and 67 individual patient interviews to capture the effects of misdiagnosis, missed diagnosis, or delayed diagnosis on patient lives. Audio recordings of patient interviews were transcribed, and a hybrid thematic analysis approach was used to capture details about 4 main domains of interest: the patient's DDF experience, contributing factors, impact, and strategies to mitigate future occurrences.ResultsDental patients endured prolonged suffering, disease progression, unnecessary treatments, and the development of new symptoms as a result of experiencing DE. Poor provider communication, inadequate time with provider, and lack of patient self-advocacy and health literacy were among the top attributes patients believed contributed to the development of a DE. Patients suggested that improvements in provider chairside manners, more detailed patient diagnostic workups, and improving personal self-advocacy; along with enhanced reporting systems, could help mitigate future DE.ConclusionsThis study demonstrates the valuable insight the patient perspective provides in understanding DEs, therefore aiding the development of strategies to help reduce the occurrences of future DDF events. Given the challenges patients expressed, there is a significant need to create an accessible reporting system that fosters constructive clinician learning

Dental patients as partners in promoting quality and safety: a qualitative exploratory study.

OBJECTIVE: Active patient involvement in promoting quality and safety is a priority for healthcare. We investigated how dental patients perceive their role as partners in promoting quality and safety across various dental care settings. METHODS: Focus group sessions were conducted at three dental practice settings: an academic dental center, a community dental clinic, and a large group private practice, from October 2018-July 2019. Patients were recruited through flyers or word-of-mouth invitations. Each session lasted 2.5 h and patients completed a demographic and informational survey at the beginning. Audio recordings were transcribed, and a hybrid thematic analysis was performed by two independent reviewers using Dedoose. RESULTS: Forty-seven participants took part in eight focus group sessions; 70.2% were females and 38.3% were aged 45-64 years. Results were organized into three major themes: patients overall perception of dental quality and safety; patients reaction to an adverse dental event; and patients role in promoting quality and safety. Dental patients were willing to participate in promoting quality and safety by careful provider selection, shared decision-making, self-advocacy, and providing post-treatment provider evaluations. Their reactions towards adverse dental events varied based on the type of dental practice setting. Some factors that influenced a patients overall perception of dental quality and safety included provider credentials, communication skills, cleanliness, and durability of dental treatment. CONCLUSION: The type of dental practice setting affected patients desire to work as partners in promoting dental quality and safety. Although patients acknowledged having an important role to play in their care, their willingness to participate depended on their relationship with their provider and their perception of provider receptivity to patient feedback

Dental Providers' Perspectives on Diagnosis-Driven Dentistry: Strategies to Enhance Adoption of Dental Diagnostic Terminology.

The routine use of standardized diagnostic terminologies (DxTMs) in dentistry has long been the subject of academic debate. This paper discusses the strategies suggested by a group of dental stakeholders to enhance the uptake of DxTMs. Through unstructured interviewing at the 'Toward a Diagnosis-Driven Profession' National Conference held on 19 March 2016 in Los Angeles, CA, USA participants were asked how enthusiastic they were about implementing and consistently using DxTMs at their work. They also brainstormed on strategies to improve the widespread use of DxTMs. Their responses are summarized by recursive abstraction and presented in themes. Conference participants were very enthusiastic about using a DxTM in their place of work. Participants enumerated several strategies to make DxTMs more appealing including: the use of mandates, a value proposition for providers, communication and education, and integration with EHRs and existing systems. All groups across the dental healthcare delivery spectrum will need to work together for the success of the widespread and consistent use of DxTMs. Understanding the provider perspective is however the most critical step in achieving this goal, as they are the group who will ultimately be saddled with the critical task of ensuring DxTM use at the point of care