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 work² 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.
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GEISTLICH NEWS 1-2022
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
