Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand.
College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand.
BMC Oral Health. 2024 Oct 26;24(1):1294. doi: 10.1186/s12903-024-05034-7.
Patient safety is a critical concern in dentistry. Adverse events (AEs) can harm patients, increase costs, and decrease satisfaction. Understanding AE types and frequencies is crucial for effective risk management and quality improvement. This study analyzes incident reports to identify preliminary incident patterns as a starting point for developing risk management strategies. However, under-reporting limits the ability to identify true incident patterns, highlighting the need for improved reporting systems and encouragement of incident reporting. Further research is underway to develop such a system and promote reporting to ensure sufficient data quality for effective risk management.
A retrospective analysis of 1,618 incident reports from December 2018 to August 2023 was conducted. A validated classification system, developed from a 5-year retrospective analysis and approved by 14 experts, categorized patient safety incidents, aligning with Thailand's Hospital Accreditation standards. Descriptive statistics summarized AE frequency and distribution.
Of the reports, 752 were patient safety, 503 personnel safety, and 363 organizational safety incidents. Top patient safety incidents included medical record errors (176), accidental damage (66), post-operative complications (65), medical emergencies (64), and communication errors (53). Personnel safety incidents involved inappropriate working conditions (135) and work-related injuries with contact transmission risk (117). Organizational safety incidents mainly concerned policy and operational processes (131).
This study reveals the preliminary patterns of adverse events (AEs) in dental settings and underscores the limitations due to under-reporting, which affect the ability to fully understand true incident patterns. To effectively manage risks, there is a critical need for improving the existing incident reporting system and encouraging a culture of comprehensive reporting among dental professionals. Future efforts should focus on enhancing reporting systems to ensure high-quality data, enabling better identification of incident trends and supporting targeted risk management strategies to improve patient safety in dentistry.
患者安全是牙科领域的一个关键关注点。不良事件（AE）可能会对患者造成伤害、增加成本并降低满意度。了解 AE 的类型和频率对于有效的风险管理和质量改进至关重要。本研究通过分析事故报告来识别初步的事故模式，以此作为制定风险管理策略的起点。然而，由于报告不足，限制了识别真实事故模式的能力，这突显了改进报告系统和鼓励事故报告的必要性。目前正在进行进一步的研究，以开发这样的系统并促进报告，以确保有足够的数据质量来进行有效的风险管理。
对 2018 年 12 月至 2023 年 8 月期间的 1618 份事故报告进行了回顾性分析。采用了一种经 5 年回顾性分析开发并经 14 名专家批准的验证分类系统，对患者安全事故进行分类，与泰国医院认证标准保持一致。描述性统计总结了 AE 的频率和分布。
报告中包括 752 起患者安全事件、503 起人员安全事件和 363 起组织安全事件。患者安全事件中排名靠前的包括医疗记录错误（176 起）、意外损伤（66 起）、术后并发症（65 起）、医疗紧急情况（64 起）和沟通错误（53 起）。人员安全事件涉及不当的工作条件（135 起）和具有接触传播风险的工作相关伤害（117 起）。组织安全事件主要涉及政策和运营流程（131 起）。
本研究揭示了牙科环境中不良事件（AE）的初步模式，并强调了由于报告不足而导致的局限性，这影响了对真实事故模式的全面理解。为了有效管理风险，迫切需要改进现有的事故报告系统，并鼓励牙科专业人员全面报告。未来的努力应侧重于加强报告系统，以确保高质量的数据，更好地识别事件趋势，并支持有针对性的风险管理策略，以提高牙科患者的安全性。
