Identifying Contributing Factors Associated With Dental Adverse Events Through a Pragmatic Electronic Health Record-Based Root Cause Analysis

Authors

Elsbeth Kalenderian
Suhasini Bangar
Alfa Yansane
Duong Tran
Emily Sedlock
Yan Xiao
Janelle Urata
Greg Olson
Amy Franklin
Krishna Kookal
Ana Ibarra-Noriega
Sayali Tungare
Oluwabunmi Tokede
Heiko Spallek
Joel M White
Muhammad F Walji

Publication Date

8-1-2023

Journal

Journal of Patient Safety

Abstract

OBJECTIVE: This study assessed contributing factors associated with dental adverse events (AEs).

METHODS: Seven electronic health record-based triggers were deployed identifying potential AEs at 2 dental institutions. From 4106 flagged charts, 2 reviewers examined 439 charts selected randomly to identify and classify AEs using our dental AE type and severity classification systems. Based on information captured in the electronic health record, we analyzed harmful AEs to assess potential contributing factors; harmful AEs were defined as those that resulted in temporary moderate to severe harm, required hospitalization, or resulted in permanent moderate to severe harm. We classified potential contributing factors according to (1) who was involved (person), (2) what were they doing (tasks), (3) what tools/technologies were they using (tools/technologies), (4) where did the event take place (environment), (5) what organizational conditions contributed to the event? (organization), (6) patient (including parents), and (7) professional-professional collaboration. A blinded panel of dental experts conducted a second review to confirm the presence of an AE.

RESULTS: Fifty-nine cases had 1 or more harmful AEs. Pain occurred most frequently (27.1%), followed by nerve injury (16.9%), hard tissue injury (15.2%), and soft tissue injury (15.2%). Forty percent of the cases were classified as "temporary not moderate to severe harm." Person (training, supervision, and fatigue) was the most common contributing factor (31.5%), followed by patient (noncompliance, unsafe practices at home, low health literacy, 17.1%), and professional-professional collaboration (15.3%).

CONCLUSIONS: Pain was the most common harmful AE identified. Person, patient, and professional-professional collaboration were the most frequently assessed factors associated with harmful AEs.

Keywords

EHR, Dentistry, Adverse Event, Patient Safety, Contributing Factors, Root Cause Analysis, Human Factors, System Engineering, Systems Engineering Initiative for Patient Safety

Comments

PMID: 37015101