Obadan Enihomo M, Ramoni Rachel B, Kalenderian Elsbeth
J Am Dent Assoc. 2015 May;146(5):318-26.e2. doi: 10.1016/j.adaj.2015.01.003.
Errors are commonplace in health care, including dentistry. It is imperative for dental professionals to intercept errors before they lead to an adverse event and to mitigate their effects when an adverse event occurs. This requires a systematic approach at both the profession level, encapsulated in the Agency for Healthcare Research and Quality's patient safety initiative framework, as well as at the practice level, in which crew resource management is a tested paradigm. Supporting patient safety at both the profession and dental practice levels relies on understanding the types and causes of errors, which have not been well studied.
The authors performed a retrospective review of dental adverse events reported in the literature. Electronic bibliographic databases were searched, and data were extracted on background characteristics, incident description, case characteristics, clinic setting where adverse event originated, phase of patient care that adverse event was detected, proximal cause, type of patient harm, degree of harm, and recovery actions.
The authors identified 182 publications (containing 270 cases) through their search. Delayed treatment, unnecessary treatment, or disease progression after misdiagnosis was the largest type of harm reported. Of the reviewed cases, 24.4% of those patients involved in an adverse event experienced permanent harm. One of every 10 case reports reviewed (11.1%) reported that the adverse event resulted in the death of the affected patient.
Published case reports provide a window into understanding the nature and extent of dental adverse events; however, the overall dearth of publications on adverse events in the dental literature points to the need for more study.
Siloed and incomplete contributions to dentistry's understanding of adverse events in the dental office are threats to dental patients' safety. Publishing more, and more comprehensive, case reports on adverse events is recommended for dental practitioners.
医疗保健领域，包括牙科，错误屡见不鲜。牙科专业人员必须在错误导致不良事件之前加以拦截，并在不良事件发生时减轻其影响。这需要在专业层面采取系统方法，如医疗保健研究与质量局的患者安全倡议框架所涵盖的那样，以及在实践层面采取系统方法，其中团队资源管理是一种经过检验的模式。在专业和牙科实践层面支持患者安全依赖于了解错误的类型和原因，而这方面的研究还很不足。
作者对文献中报道的牙科不良事件进行了回顾性研究。检索了电子文献数据库，并提取了有关背景特征、事件描述、病例特征、不良事件发生的临床环境、发现不良事件的患者护理阶段、近端原因、患者伤害类型、伤害程度和恢复措施的数据。
作者通过检索确定了182篇出版物（包含270个病例）。报告的最大伤害类型是误诊后治疗延迟、不必要的治疗或疾病进展。在审查的病例中，参与不良事件的患者中有24.4%遭受了永久性伤害。每10份审查的病例报告中有1份（11.1%）报告称不良事件导致了受影响患者的死亡。
已发表的病例报告为了解牙科不良事件的性质和程度提供了一个窗口；然而，牙科文献中关于不良事件的出版物总体匮乏，这表明需要更多的研究。
牙科领域对牙科诊所不良事件的孤立和不完整的认识对牙科患者的安全构成威胁。建议牙科从业者发表更多、更全面的不良事件病例报告。
