Sir, my oral surgery colleagues and I were rather surprised by the recent announcement that wrong tooth extraction is to be removed from the list of Never Events (NE) as stipulated by NHS Improvement on 1 April 2021.1
The reason given for this change is that 'The systemic barriers to prevent the removal of wrong teeth are considered not to be strong enough to prevent these from occurring eg lack of standardisation in types of tooth notation and difficulties with site marking'. On initial reading of this, one may feel that this is a victory for common sense, although I feel that the interpretation of this is slightly more nuanced. Removal of the wrong tooth is still considered to be a serious event which must be reported and investigated, however, this announcement changes the framework through which such events will be investigated.
Having devoted much time and effort to patient safety in dentistry, this is broadly a positive step. The removal of this from the list (frequently the most common surgical NE) will allow more focus on other NE.2 However, I am slightly cautious about what this means for dentistry within the NHS. I hope that this change does not lead to a downgrading of patient safety in dentistry which is still an area that requires development.3 Safety and quality are inexorably linked and I worry that if the first is dimmed a decline in quality may follow. There is still no accepted framework that defines patient safety incidents in dentistry.4 Too much focus has been on wrong tooth extractions because, aside from death in the dental surgery, this is the most tangible adverse event that can occur.
I was never at ease with the term 'Never Event', feeling that it has too much onus on the negative. In my experience, the approach has improved in recent years, with 'patient safety cultures' developing across the profession. Perhaps a framework of 'Always Events' for dentistry is the way forward: we always check we have the right patient, we always provide the correct treatment, we always report and learn from incidents.
NHS Improvement. Never Events list 2018. January 2018, updated February 2021. Available at: https://www.england.nhs.uk/wp-content/uploads/2020/11/2018-Never-Events-List-updated-February-2021.pdf (accessed March 2021).
Pemberton M N. Wrong tooth extraction: further analysis of 'never event' data. Br J Oral Maxillofac Surg 2019; 57:932-934.
Bailey E, Tickle M, Campbell S, O'Malley L. Systematic review of patient safety interventions in dentistry. BMC Oral Health 2015; 15: 152.
Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care. Br Dent J 2017; 222: 782-788.