A Culture of Safety: Why Reinvent the Wheel?
No patient should die in the dental office. With few exceptions, deep sedation and general anesthesia for dentistry is performed in the office-based environment on patients without significant medical compromise while moderate sedation is provided for a wider range of patients. Those patients with undue risks are routinely referred to a hospital or surgery center, so patient deaths in the dental office should be exceptionally rare.
Yet in mid-July, a story involving the death of a dental patient circulated throughout the national news, sadly marking the second such report that month. Consistent with most initial news releases covering these types of incidents, the article shared only sparse information centered on second- and third-hand accounts, leading to ample speculation among professionals and the public alike. Little could be gained in terms of appreciating any likely causes or contributing factors. It was not even clear if the anesthesia provider was a dentist, physician, or nurse. Notably, had either of these tragedies occurred in a hospital, the stories would almost certainly not have been featured in the news.
Although the true occurrence rate of substantial morbidity and mortality tied to sedation or general anesthesia in the dental office is virtually impossible to ascertain accurately, conservative estimates approach 1 event every 6 weeks based on historical information derived from closed claims databases. However, the rate is likely higher, perhaps averaging more than 1 event per month, as such databases fail to encompass all providers utilizing sedation and general anesthesia for dental treatment. Simply put, this is an ongoing issue that rests squarely on all our shoulders, even if a number of these deaths occur while the patient is under the care of a physician or nurse.
Typically, discussion of such a delicate subject is fraught with potential political and legal implications. There is no question that the presence of conflicts of interest, both real and perceived, often muddy the waters further. My intent is not to discuss the more controversial issues, like training requirements, licensure, or supervision (ie, who should be permitted to do what), but rather to draw attention to the gaping flaws within our current system that should provide professional oversight and guidance, ultimately to effect continuing improvement.
The concept of evidence-based medicine has been around for quite some time, originating in the 19th century. Adoption and integration into dentistry has been slow, although momentum is undeniable. Sadly, it is almost impossible to apply an evidence-based approach effectively to the ongoing issues of sedation and general anesthesia-related morbidity and mortality in dentistry due to the absence of comprehensive data. Dentistry lacks a clear concise accounting of not only the numerator (ie, number of adverse anesthesia outcomes) but also the overall denominator (ie, how many cases each of moderate sedation, deep sedation, and general anesthesia are performed per year). Furthermore, state dental boards effectively discourage disclosure of relevant information from cases involving poor outcomes. Although the reasons are multifactorial, compounding this problem is the relative isolation of the typical dental practice that simply does not lend itself well to self-reporting and therefore “Big Data.” Without data access, it is virtually impossible for providers to perform root cause analysis effectively in order to identify and address any recurrent underlying issues. If we don't know what's broken, how can we fix it?
Throughout the years, the general field of anesthesiology has successfully borrowed many safety optimizing approaches from the aviation industry, which has been a leader in safety analysis. Commonplace anesthesiology protocols such as preoperative checklists, emergency response flowcharts, and simulation all have roots stemming from within aviation. Even the terms used to describe the stages of anesthesia often evoke thoughts related to flying (induction/takeoff; maintenance/cruising; and emergence/landing). In the early years, flying was considered relatively unsafe, and as commercial aviation grew, incidents were occurring with increased regularity and beginning to erode public trust. The US airline industry responded with a multifaceted approach that included strict regulatory oversight from the Federal Aviation Administration (FAA) along with the aforementioned safety measures, all primarily guided by data. The safety initiatives implemented by the aviation industry significantly increased air travel safety to the point that safety concerns during domestic commercial flights are statistically incredibly rare events.
Importantly, the FAA has continued to innovate despite their successes. Prior to 2015, more traditional regulatory methods, such as fines and civil penalties, were used to ensure compliance. However, the FAA changed course in 2015 after concluding that the strict use of punitive approaches promoted a culture that disincentivized self-reporting and disclosure of potentially negative information. They now stress a “collaborative problem-solving approach (ie, engagement, root-cause analysis, transparency, and information exchange)” built upon a culture where self-reporting is not only appreciated but expected, “where the goal is to enhance the safety performance of individuals and organizations.” Although punitive enforcement methods may still be applied when absolutely indicated, their overall goal is to work together to identify problems and take effective corrective actions proactively.1
Given the apparent room for improvement in safety analysis, our profession as a whole could benefit from adapting yet another aviation industry model. State dental boards should consider following in the footsteps of the FAA and work to build an improved safety culture based more on collaboratively solving problems and less on traditional punitive regulation enforcement. The increased level of transparency and communication surrounding adverse events has ultimately increased the level of safety in aviation; implementing similar measures in dentistry would no doubt have the same effect.
Dental boards should also reconsider the way data from cases with adverse outcomes are disclosed for subsequent professional review. Proper analysis of data regarding emergencies managed in the dental office, hospitalizations, and critical outcomes would allow the profession to identify recurring trends and respond by creating effective solutions to improve patient safety. One potential avenue may be for state dental boards to utilize a nationwide protected database such as that developed by the Dental Patient Safety Foundation (DPSF; www.dentalpatientsafety.org). The DPSF, based on the Anesthesia Patient Safety Foundation's (www.apsf.org) organizational paradigm, is an independent, apolitical, multidisciplinary Patient Safety Organization (PSO).2 Utilizing a web-based reporting tool modeled after the Anesthesia Quality Institute's Anesthesia Incident Reporting System, it maintains a database that functions as a repository for information about any dental-related patient safety event, not just anesthesia-related complications.3 As a federally protected PSO, the DPSF ensures strict, legally protected confidentiality of any submitted events, and it generates de-identified reports after internal analysis that serve to inform and guide practitioners in the future, all in the name of improved safety. In most states, licensed dentists are legally required to report significant adverse events (eg, unexpected hospitalizations, significant morbidity, death) to their respective state dental boards. Bureaucratic red tape aside, it seems only logical that information disclosed to all state dental boards could be shared with the DPSF, or another PSO, for a truly national database that would be available to everyone in the profession. The benefits of such a revolutionary systematic approach seem to clearly outweigh the negatives.
Risk will forever be inherent to patient care, particularly when sedation or general anesthesia is used. There is ample room to further improve the culture of safety within dentistry and much to be gained from the use of “Big Data,” assuming it is made readily accessible to our profession. Progress is often uncomfortable and would require scrapping long-standing systems that currently fail to deliver what the profession and public want: a clear path to minimizing adverse anesthesia outcomes in dental offices. Organized dentistry and professional dental societies, which emphasize sedation or general anesthesia as part of their specialties should work with dental boards to explore more effective solutions, and rather than reinvent the wheel, consider adapting some of aviation's successful approaches to establish a more optimal culture of safety.