Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Developing agreement on never events in primary care dentistry: an international eDelphi study

Key Points

  • 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.

This is a preview of subscription content, access via your institution

Access options

Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Figure 1: International expert consensus-based Delphi method.


  1. Jha A . Summary of the evidence on patient safety: implications for research Spain. World Health Organiszation, 2008. Available at (accessed April 2018).

  2. 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.

    Article  Google Scholar 

  3. The Safer Primary Care Expert Working Group. Safer Primary Care: A Global Challenge. Switzerland. World Health Organisation, 2012.

  4. Carson-Stevens A, Edwards A, Panesar S et al. Reducing the burden of iatrogenic harm in children. Lancet 2015; 385: 1593–1594.

    Article  Google Scholar 

  5. World Health Organisation. IBEAS: a pioneer study on patient safety in Latin America. Towards safer hospital care. Geneva, Switzerland: World Health Organisation, 2011.

  6. 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.

    Article  Google Scholar 

  7. 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.

    Article  Google Scholar 

  8. World Health Organisation. Global Priorities for Patient Safety Research Better knowledge for safer care. 2008.

  9. 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.

    Article  Google Scholar 

  10. 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.

    Article  Google Scholar 

  11. Kohn L T, Corrigan J M, Donaldson M S . To Err Is Human: Building a Safer Health System. National Academies Press, 2000.

  12. World Health Organisation. World Health Assembly Resolution WHA 55.18 2012. Available at (accessed April 2018).

  13. National Patient Safety Agency. Patient Safety – Never Events. NHS, 2015 Available at (accessed April 2018).

  14. 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.

    Article  Google Scholar 

  15. Wilson T, Sheikh A . Enhancing public safety in primary care. BMJ 2002; 324: 584–587.

    Article  Google Scholar 

  16. Centers for Medicare & Medicaid Services. The Deficit Reduction Act. 2005. Available at (accessed April 2018).

  17. Department of Health. The never events policy framework: An update to the never events policy. London: National Health Service, 2012.

  18. Department of Health. Revised Never Events Policy and Framework. London: National Health Service, 2015.

  19. The Canadian Patient Safety Institute. Never Events for Hospital Care in Canada. Canada, 2015.

  20. The Australian Commission on Safety and Quality in Health Care. Australian Safety and Quality Framework for Health Care. Australia, 2010 Available at (accessed April 2018).

  21. Department of Health. Revised Serious Incident Framework. NHS Improvement, 2015.

  22. Harrop-Griffiths W . Never events. Anaesthesia 2011; 66: 158–162.

    Article  Google Scholar 

  23. Department of Health. Provisional publication of Never Events reported as occurring between 1 April 2014 and 31 March 2015. NHS Improvement, 2015.

  24. Sheikh A, Panesar S S, Larizgoitia I et al. Safer primary care for all: a global imperative. Lancet Global Health 2013; 1: E182–E183.

    Article  Google Scholar 

  25. Sheikh A, Bates D W . Iatrogenic harm in primary care. Harvard Health Policy Review 2014; 4: 4–8.

    Google Scholar 

  26. Bailey E, Tickle M, Campbell S . Patient safety in primary care dentistry: where are we now? Br Dent J 2014; 217: 339–344.

    Article  Google Scholar 

  27. Bailey E, Tickle M, Campbell S et al. Systematic review of patient safety interventions in dentistry. BMC Oral Health 2015; 15: 152.

    Article  Google Scholar 

  28. 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.

    Article  Google Scholar 

  29. 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.

    Article  Google Scholar 

  30. 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.

  31. 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.

    Article  Google Scholar 

  32. Renton T, Sabbah W . Review of never and serious events related to dentistry 2005–2014. Br Dent J 2016; 221: 71–79.

    Article  Google Scholar 

  33. 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

    Article  Google Scholar 

  34. Fink A, Kosecoff J, Chassin M et al. Consensus Methods – Characteristics and Guidelines for Use. Am J Public Health 1984; 74: 979–983.

    Article  Google Scholar 

  35. Sackman H . Delphi assessment: Expert opinion, forecasting, and group process. DTIC Document. 1974.

  36. Rowe G, Wright G, Bolger F . Delphi – a Reevaluation of Research and Theory. Technolog Forecast Soc Change 1991; 39: 235–251.

    Article  Google Scholar 

  37. Okoli C, Pawlowski S D . The Delphi method as a research tool: an example, design considerations and applications. Inform Manag 2004; 42: 15–29.

    Article  Google Scholar 

  38. Steurer J . The Delphi method: an efficient procedure to generate knowledge. Skeletal Radiol 2011; 40: 959–961.

    Article  Google Scholar 

  39. de Meyrick J . The Delphi method and health research. Health Educ 2003; 103: 7–16.

    Article  Google Scholar 

  40. Helmer O . Analysis of the future: The Delphi method. DTIC Document. 1967.

  41. 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.

    PubMed  Google Scholar 

  42. 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.

    Article  Google Scholar 

  43. 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.

    Article  Google Scholar 

  44. Brown BB . Delphi process: A methodology used for the elicitation of opinions of experts. DTIC Document. 1968.

  45. Microsoft. Excel. Redmond, WA: Microsoft Corporations, 2011.

  46. 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.

    Article  Google Scholar 

  47. 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.

    Article  Google Scholar 

  48. Berger E R, Greenberg C C, Bilimoria K Y . Challenges in Reducing Surgical 'Never Events'. J Am Med Assoc 2015; 314: 1386–1387.

    Article  Google Scholar 

  49. Council of European Dentists. Resolution on Patient Safety. 2008.

  50. Boysen P G . Just culture: a foundation for balanced accountability and patient safety. Ochsner J 2013; 13: 400–406.

    PubMed  PubMed Central  Google Scholar 

  51. Ovretveit J . Understanding and improving patient safety: the psychological, social and cultural dimensions. J Health Org Manag 2009; 23: 581–596.

    Article  Google Scholar 

  52. Agency for Healthcare Research & Quality. Never events. 2016. Available at (accessed April 2018).

  53. Austin J M, Pronovost PJ . 'Never events' and the quest to reduce preventable harm. Jt Comm J Qual Patient Saf 2015; 41: 279–288.

    Article  Google Scholar 

  54. Makar A, Kodera A, Bhayani S B . Never Events in Surgery. Elsevier, 2015.

    Book  Google Scholar 

  55. General Dental Council. Standards for the dental team. GDC, London. 2013.

  56. CQC. Reporting IRMER incidents. Care Quality Commission, 2017.

  57. Renton T, Master S . The complexity of patient safety reporting systems in UK dentistry. Br Dent J 2016; 221: 517–524.

    Article  Google Scholar 

  58. Mayer E FK, Callahan R, Darzi A . National Reporting and Learning System Research and Development. England: NHIT Imperial Patient Safety Translational Research Centre, 2016.

  59. Department of Health. The future of the patient safety incident reporting: upgrading the NRLS. UK: National Health Service, 2017. Available at (accessed April 2018).

  60. 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.

    Article  Google Scholar 

  61. World Health Organisation. Education and Training: Technical Series on Safer Primary Care. Geneva: World Health Organisation; 2016.

  62. Bader J D . Challenges in quality assessment of dental care. J Am Med Assoc 2009; 140: 1456–1464.

    Google Scholar 

  63. 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.

  64. Professionals Standards Authority. Homepage. Available at (accessed April 2018).

  65. General Medical Council. Homepage. Available at (accessed April 2018).

  66. General Dental Council. Homepage. Available at (accessed April 2018).

  67. Care Quality Commission. Homepage. Available at (accessed April 2018).

  68. National Clinical Assessment Service. Homepage. Available at (accessed April 2018).

  69. Porto G G . Safety by design: ten lessons from human factors research. J Healthc Risk Manag 2001; 21: 43–50.

    PubMed  Google Scholar 

  70. 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.

    Article  Google Scholar 

  71. 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.

    Article  Google Scholar 

  72. 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.

    Article  Google Scholar 

  73. 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.

    Google Scholar 

  74. 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.

    Article  Google Scholar 

  75. Pemberton MN . Developing patient safety in dentistry. Br Dent J 2014; 217: 335–337.

    Article  Google Scholar 

  76. World Health Organisation. WHO patient safety curriculum guide: multi-professional edition. WHO Press, 2011.

  77. World Health Organisation. WHO Patient Safety Curriculum Guide for Medical Schools: WHO Press, 2009.

  78. Carson-Stevens A, Donaldson L . Reporting and learning from patient safety incidents in general practice: a practical guide. Royal College of General Practitioners, 2017.

  79. 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.

    PubMed  PubMed Central  Google Scholar 

  80. Sheikhtaheri A . Near Misses and Their Importance for Improving Patient Safety. Iran J Public Health 2014; 43: 853–854.

    PubMed  PubMed Central  Google Scholar 

  81. World Health Organisation. Human Factors: Technical Series on Safer Primary Care. Geneva: World Health Organization, 2016.

  82. Vincent C, Taylor-Adams S, Stanhope N . Framework for analysing risk and safety in clinical medicine. BMJ 1998; 316: 1154–1157.

    Article  Google Scholar 

  83. Reason J . Human error: models and management. BMJ 2000; 320: 768–770.

    Article  Google Scholar 

  84. 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.

    Article  Google Scholar 

  85. 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.

    Article  Google Scholar 

Download references


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.

Author information

Authors and Affiliations


Corresponding author

Correspondence to E. Ensaldo-Carrasco.

Supplementary information

Supplementary information

Supplementary Tables (PDF 74 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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).

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:

This article is cited by


Quick links