Human factors , errors and patient safety
“ The main factor in the etiology of error is time pressure .”
Simon Wright MBE | United Kingdom Director of the ICE Hospital and Postgraduate Training Centre , UK
Ulpee Darbar | United Kingdom Consultant in Restorative Dentistry and Director of Dental Education at Eastman Dental Hospital , UK
Interview conducted by Marjan Gilani
Dental teams make at least two errors per day , of which 1.4 % may lead to an adverse event .¹ In this interview , the deputy and chairperson of the Advisory Board for Human Factors in Dentistry in the UK expand on the topics of awareness , errors and patient safety .
Prof . Wright , when did you become interested in the topic of Human Factors and Errors in dentistry ?
Prof . Wright : My interest in the subject originated from a passion to drive safety in our teaching clinics . We wanted to develop protocols and processes that would help the students ensure that teaching clinics were as safe as possible . We listened to the work of our good friend Franck Renouard speaking about Human Factors at a conference , and his work ² resonated with our thinking . What we were trying to do was exactly what Franck was talking about . When we introduced Human Factors into our clinics we started seeing not only what errors and mishaps occur but also the barriers that stop people from being open about them .
How was it for you Dr . Darbar ?
Dr . Darbar : I work in a university hospital and in a dental practice too , so I am exposed to a wide range of challenges and mishaps of varying kinds . My personal experience was the observation that things were not working according to plan , but when trying to address the issue , people did not want to come forward , as they feared being blamed . These challenges made my team look at things differently . Our methods of using afteraction reviews showed that a simple mishap was clouded by multiple factors that we today refer to as Human Factors .
After discussing with Simon , we realized that we were in different ways trying to address a number of the issues that were aligned , but in different settings . This was the beginning of the
National Advisory Board for Human Factors in Dentistry ( NABHF ), which was established in July 2018 .
What is the core mission of the board ?
We want to raise awareness and understanding of human factors across all sectors in which dentistry is delivered , and work towards empowering a culture of openness in which “ blame ” is not the focus .³ Our aspiration is to move mindsets of dental care providers , teams , policymakers and regulators away from the fear of “ retribution and reprimand ” to one of openness , channeling the concept of “ something will go wrong , and how are we going to deal with it ,” and embedding this ethos into the day-to-day working environment .
Are there some clinical errors that happen more frequently ? And if so , why ?
Latent risk factors , such as communication errors , equipment- , environment- , systems-related and stress and fatigue , play major roles in errors and mishaps . However , the consequences of common human error in dentistry , like wrong tooth extraction and wrong-site surgery , do not , in most cases , lead to fatality , and as such , the emphasis is based on patient safety . For example , staff working with experienced clinicians are often afraid to raise any concerns . An experienced clinician is fitting an implant screw-retained crown in a patient using some very small drivers . The nurse assisting tried to suggest the use of floss tied to the driver to stop it from falling . The clinician ignored the suggestion and continued with the treatment . During this time , the patient suddenly moved and the clinician dropped the driver into the mouth
14 GEISTLICH NEWS 1-2022