Presents an international perspective about 'never events' in dentistry.
Outlines a list of events that can support quality assessment and governance activities.
Provides a starting point for further patient safety research opportunities to build the evidence base that can be translated into action.
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Jha A . Summary of the evidence on patient safety: implications for research Spain. World Health Organiszation, 2008. Available at http://www.who.int/patientsafety/information_centre/20080523_Summary_of_the_evidence_on_patient_safety.pdf (accessed April 2018).
Jha A K, Prasopa-Plaizier N, Larizgoitia I, Bates D W, Research Priority Setting Working Group of the WHOWAfPS. Patient safety research: an overview of the global evidence. Qual Saf Health Care 2010; 19: 42–47.
The Safer Primary Care Expert Working Group. Safer Primary Care: A Global Challenge. Switzerland. World Health Organisation, 2012.
Carson-Stevens A, Edwards A, Panesar S et al. Reducing the burden of iatrogenic harm in children. Lancet 2015; 385: 1593–1594.
World Health Organisation. IBEAS: a pioneer study on patient safety in Latin America. Towards safer hospital care. Geneva, Switzerland: World Health Organisation, 2011.
de Vries E N, Ramrattan M A, Smorenburg S M et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008; 17: 216–223.
Bartlett G, Blais R, Tamblyn R, Clermont R J, MacGibbon B . Impact of patient communication problems on the risk of preventable adverse events in acute care settings. CMAJ 2008; 178: 1555–1562.
World Health Organisation. Global Priorities for Patient Safety Research Better knowledge for safer care. 2008.
Panesar S S, Carson-Stevens A, Cresswell K M et al. How safe is primary care? A systematic review. BMJ Qual Saf 2015; 25: 544–553.
Brennan T A, Leape L L, Laird N M et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370–376.
Kohn L T, Corrigan J M, Donaldson M S . To Err Is Human: Building a Safer Health System. National Academies Press, 2000.
World Health Organisation. World Health Assembly Resolution WHA 55.18 2012. Available at http://apps.who.int/gb/archive/pdf_files/WHA55/ewha5518.pdf?ua=1&ua=1 (accessed April 2018).
National Patient Safety Agency. Patient Safety – Never Events. NHS, 2015 Available at http://www.nrls.npsa.nhs.uk/neverevents/ (accessed April 2018).
World Alliance For Patient Safety Drafting G, Sherman H, Castro G et al. Towards an International Classification for Patient Safety: the conceptual framework. Int J Qual Helath Care 2009; 21: 2–8.
Wilson T, Sheikh A . Enhancing public safety in primary care. BMJ 2002; 324: 584–587.
Centers for Medicare & Medicaid Services. The Deficit Reduction Act. 2005. Available at https://www.cms.gov/Regulations-and-Guidance/Legislation/DeficitReductionAct/index.html (accessed April 2018).
Department of Health. The never events policy framework: An update to the never events policy. London: National Health Service, 2012.
Department of Health. Revised Never Events Policy and Framework. London: National Health Service, 2015.
The Canadian Patient Safety Institute. Never Events for Hospital Care in Canada. Canada, 2015.
The Australian Commission on Safety and Quality in Health Care. Australian Safety and Quality Framework for Health Care. Australia, 2010 Available at https://www.safetyandquality.gov.au/national-priorities/australian-safety-and-quality-framework-for-health-care/ (accessed April 2018).
Department of Health. Revised Serious Incident Framework. NHS Improvement, 2015.
Harrop-Griffiths W . Never events. Anaesthesia 2011; 66: 158–162.
Department of Health. Provisional publication of Never Events reported as occurring between 1 April 2014 and 31 March 2015. NHS Improvement, 2015.
Sheikh A, Panesar S S, Larizgoitia I et al. Safer primary care for all: a global imperative. Lancet Global Health 2013; 1: E182–E183.
Sheikh A, Bates D W . Iatrogenic harm in primary care. Harvard Health Policy Review 2014; 4: 4–8.
Bailey E, Tickle M, Campbell S . Patient safety in primary care dentistry: where are we now? Br Dent J 2014; 217: 339–344.
Bailey E, Tickle M, Campbell S et al. Systematic review of patient safety interventions in dentistry. BMC Oral Health 2015; 15: 152.
Yamalik N, Van Dijk W . Analysis of the attitudes and needs/demands of dental practitioners in the field of patient safety and risk management. Int Dent J 2013; 63: 291–297.
Yamalik N, Perea Perez B . Patient safety and dentistry: what do we need to know? Fundamentals of patient safety, the safety culture and implementation of patient safety measures in dental practice. Int Dent J 2012; 62: 189–196.
Ensaldo-Carrasco E, Suarez-Ortegon M F, Carson-Stevens A, Cresswell K, Bedi R, Sheikh A . Patient Safety Incidents and Adverse Events in Ambulatory Dental Care: A Systematic Scoping Review. J Patient Saf 2016; Published online ahead of print.
Thusu S, Panesar S, Bedi R . Patient safety in dentistry – state of play as revealed by a national database of errors. Br Dent J 2012; 213: E3.
Renton T, Sabbah W . Review of never and serious events related to dentistry 2005–2014. Br Dent J 2016; 221: 71–79.
Black I, Bowie P . Patient Safety in primary care dentistry: Development of candidate 'never event' list to support team learning and system improvement. Br Dent J 2017; 222: 782–788
Fink A, Kosecoff J, Chassin M et al. Consensus Methods – Characteristics and Guidelines for Use. Am J Public Health 1984; 74: 979–983.
Sackman H . Delphi assessment: Expert opinion, forecasting, and group process. DTIC Document. 1974.
Rowe G, Wright G, Bolger F . Delphi – a Reevaluation of Research and Theory. Technolog Forecast Soc Change 1991; 39: 235–251.
Okoli C, Pawlowski S D . The Delphi method as a research tool: an example, design considerations and applications. Inform Manag 2004; 42: 15–29.
Steurer J . The Delphi method: an efficient procedure to generate knowledge. Skeletal Radiol 2011; 40: 959–961.
de Meyrick J . The Delphi method and health research. Health Educ 2003; 103: 7–16.
Helmer O . Analysis of the future: The Delphi method. DTIC Document. 1967.
Avery A, Savelyich B, Sheikh A et al. Identifying and establishing consensus on the most important safety features of GP computer systems: e-Delphi study. Inform Prim Care 2005; 13: 3–11.
Worth A, Nurmatov U, Sheikh A . Key components of anaphylaxis management plans: consensus findings from a national electronic Delphi study. JRSM Short Rep 2010; 1: 42.
de Wet C, O'Donnell C, Bowie P . Developing a preliminary 'never event' list for general practice using consensus-building methods. Br J Gen Pract 2014; 64: e159–e167.
Brown BB . Delphi process: A methodology used for the elicitation of opinions of experts. DTIC Document. 1968.
Microsoft. Excel. Redmond, WA: Microsoft Corporations, 2011.
Williams H, Edwards A, Hibbert P et al. Harms from discharge to primary care: mixed methods analysis of incident reports. Br J Gen Pract 2015; 65: e829–e837.
Rees P, Edwards A, Powell C et al. Pediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database. Vaccine 2015; 33: 3873–3880.
Berger E R, Greenberg C C, Bilimoria K Y . Challenges in Reducing Surgical 'Never Events'. J Am Med Assoc 2015; 314: 1386–1387.
Council of European Dentists. Resolution on Patient Safety. 2008.
Boysen P G . Just culture: a foundation for balanced accountability and patient safety. Ochsner J 2013; 13: 400–406.
Ovretveit J . Understanding and improving patient safety: the psychological, social and cultural dimensions. J Health Org Manag 2009; 23: 581–596.
Agency for Healthcare Research & Quality. Never events. 2016. Available at https://psnet.ahrq.gov/primers/primer/3/never-events (accessed April 2018).
Austin J M, Pronovost PJ . 'Never events' and the quest to reduce preventable harm. Jt Comm J Qual Patient Saf 2015; 41: 279–288.
Makar A, Kodera A, Bhayani S B . Never Events in Surgery. Elsevier, 2015.
General Dental Council. Standards for the dental team. GDC, London. 2013.
CQC. Reporting IRMER incidents. Care Quality Commission, 2017.
Renton T, Master S . The complexity of patient safety reporting systems in UK dentistry. Br Dent J 2016; 221: 517–524.
Mayer E FK, Callahan R, Darzi A . National Reporting and Learning System Research and Development. England: NHIT Imperial Patient Safety Translational Research Centre, 2016.
Department of Health. The future of the patient safety incident reporting: upgrading the NRLS. UK: National Health Service, 2017. Available at https://improvement.nhs.uk/news-alerts/development-patient-safety-incident-management-system-dpsims/ (accessed April 2018).
Cresswell K M, Panesar S S, Salvilla S A et al. Global research priorities to better understand the burden of iatrogenic harm in primary care: an international Delphi exercise. PLoS Med 2013; 10: e1001554.
World Health Organisation. Education and Training: Technical Series on Safer Primary Care. Geneva: World Health Organisation; 2016.
Bader J D . Challenges in quality assessment of dental care. J Am Med Assoc 2009; 140: 1456–1464.
Pronovost P J R, A D. Stoll R A . Kennedy S B . Transforming Patient Safety: A Sector-Wide Systems Approach. World Innovation Summit for Health (WISH), 2015.
Professionals Standards Authority. Homepage. Available at http://www.professionalstandards.org.uk/ (accessed April 2018).
General Medical Council. Homepage. Available at http://www.gmc-uk.org/ (accessed April 2018).
General Dental Council. Homepage. Available at https://www.gdc-uk.org/Pages/default.aspx (accessed April 2018).
Care Quality Commission. Homepage. Available at http://www.cqc.org.uk/ (accessed April 2018).
National Clinical Assessment Service. Homepage. Available at http://www.ncas.nhs.uk/ (accessed April 2018).
Porto G G . Safety by design: ten lessons from human factors research. J Healthc Risk Manag 2001; 21: 43–50.
Perea-Perez B, Santiago-Saez A, Garcia-Marin F et al. Proposal for a 'surgical checklist' for ambulatory oral surgery. Int J Oral Maxillofac Surg 2011; 40: 949–954.
Diaz-Flores-Garcia V, Perea-Perez B, Labajo-Gonzalez E et al. Proposal of a 'Checklist' for endodontic treatment. J Clin Exp Dent 2014; 6: e104–e109.
Saksena A, Pemberton M N, Shaw A et al. Preventing wrong tooth extraction: experience in development and implementation of an outpatient safety checklist. Br Dent J 2014; 217: 357–362.
Christman A, Schrader S, John V et al. Designing a safety checklist for dental implant placement: a Delphi study. J Am Med Assoc 2014; 145: 131–140.
Lewis R Q, Fletcher M . Implementing a national strategy for patient safety: lessons from the National Health Service in England. Qual Saf Health Care 2005; 14: 135–139.
Pemberton MN . Developing patient safety in dentistry. Br Dent J 2014; 217: 335–337.
World Health Organisation. WHO patient safety curriculum guide: multi-professional edition. WHO Press, 2011.
World Health Organisation. WHO Patient Safety Curriculum Guide for Medical Schools: WHO Press, 2009.
Carson-Stevens A, Donaldson L . Reporting and learning from patient safety incidents in general practice: a practical guide. Royal College of General Practitioners, 2017.
Battles J B, Lilford R J . Organizing patient safety research to identify risks and hazards. Qual Saf Health Care. 2003; 12 (suppl 2): ii2–ii7.
Sheikhtaheri A . Near Misses and Their Importance for Improving Patient Safety. Iran J Public Health 2014; 43: 853–854.
World Health Organisation. Human Factors: Technical Series on Safer Primary Care. Geneva: World Health Organization, 2016.
Vincent C, Taylor-Adams S, Stanhope N . Framework for analysing risk and safety in clinical medicine. BMJ 1998; 316: 1154–1157.
Reason J . Human error: models and management. BMJ 2000; 320: 768–770.
Carson-Stevens A, Hibbert P, Avery A et al. A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice. BMJ Open 2015; 5: e009079.
Rudan I, Gibson J L, Ameratunga S et al. Setting priorities in global child health research investments: guidelines for implementation of CHNRI method. Croat Med J 2008; 49: 720–733.
We are grateful to the international panel of experts who so kindly gave of their time to support this work. The authors also express their gratitude to the Mexican National Council for Science and Technology (CONACYT) for the sponsorship of the first author within the PhD programme at the University of Edinburgh.
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Ensaldo-Carrasco, E., Carson-Stevens, A., Cresswell, K. et al. Developing agreement on never events in primary care dentistry: an international eDelphi study. Br Dent J 224, 733–740 (2018). https://doi.org/10.1038/sj.bdj.2018.351
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