In my experience, compared to other health-care settings, safety in dentistry has typically been relegated to a secondary priority. The perception is that dental care is lower risk, with errors causing significantly less morbidity, mortality, and financial impact than in other medical fields.
Unfortunately, this often cavalier approach has led to numerous cases of infection and injury.1 The dental practices involved came under heavy investigation by health officials, which resulted in severe legal and financial consequences.
Understanding the concepts of patient safety and culture
Today, dental and patient safety are important topics of research. Experiences in medicine, psychology, and social sciences have all contributed to several foundational concepts for patient safety. One definition of patient safety specific to health care is to “provide care that focuses on minimizing the risk of unnecessary harm to patients.”2
The concept of safety culture originated from the 1986 Chernobyl nuclear disaster, where professionals worldwide were puzzled about the factors that caused the tragic events in the Ukrainian nuclear power plant to unfold.3 Although it also has several working concepts, the general definition of safety culture is “the systems of knowledge shared by a relatively large group of people.”
Graphic OSHA violations: Don't let this happen to you
Dental impression disinfection recommendations and best practices
An organization’s safety culture combines the values, attitudes, and behaviors that determine the commitment toward a health and safety program. When it comes to dentistry, establishing a safety culture involves placing the well-being of patients and staff as the highest priority. Improving safety enhances the quality of care—a crucial element in organization evolution and development.
High-reliability organizations
High-reliability organizations (HROs) are those that meet safety, quality, and efficiency objectives via the implementation of five fundamental principles:
- Preoccupation with failure for identifying opportunities to improve
- Sensitivity to operations from heightened awareness to warning signs and indicators
- Deference to expertise by placing a value on knowledgeable, senior staff members
- Reluctance to simplify by taking no shortcuts
- Practicing resilience by going through unlikely but possible system failures
Industries such as nuclear power, aviation, and military aircraft carriers that deal with hazardous and unpredictable conditions day-to-day demonstrate how to employ these principles to keep errors to a minimum despite being in high-volatility environments.4
To truly understand the type of culture and skills necessary for becoming an HRO, we can look to the model developed by Drs. Allan Frankel and Michael Leonard titled, “A Framework for Safe, Reliable, and Effective Care.”5 It is applicable in virtually any health-care setting. The framework illustrates a clear pathway for improvements in establishing a patient safety-oriented organization.
Leadership, the development of a culture of safety, and an accessible learning system are all essential to creating and sustaining a culture that provides safe, high-quality care. All components of the framework must exist; otherwise, learning would be unsustainable, and any progress made will be short-lived.
Developing and practicing “Just culture”
Practicing just culture is crucial to creating a safety culture that engages the workforce. Instead of blaming and shaming those involved during an incident, just culture is about fostering a culture of trust, learning, and accountability. How an organization responds when something goes wrong determines whether employees feel safe enough to make a report and take responsibility.
Reporting of safety events
The purpose of this is not to assign blame but to make employees feel safe enough to report whenever incidences occur. Subsequently, the events that led to an incident can be understood and a solution developed to prevent it from happening again.
When things go wrong, and a company’s first reaction is to penalize, punish, or fire employees, it is a missed opportunity for identifying problems, learning, growth, and improvement. This can lead to continued stressful situations.
Psychological safety
The general definition of psychological safety is “a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes.”6 In this type of environment, employees feel comfortable asking questions, voicing opinions or ideas, reporting mistakes, or asking for feedback to advance themselves. It is a critical factor in developing high-performing teams as it enhances employee engagement and prevents “group thinking,” which improves overall performance.
Root cause analysis
Root cause analysis (RCA) is a problem-solving technique that seeks to discover and treat the underlying causes of an issue, as opposed to only addressing its symptoms.7 The goal is to identify the hows and whys to prevent future harm by eliminating factors that led to the errors. Mobilization of a multidisciplinary team to analyze the sequence of events is necessary.
The five whys technique, originally developed to trace the root cause of problems in the manufacturing of Toyota Motors to determine the fundamental cause of manufacturing difficulties, is also a helpful tool in RCA.
Five elements are involved in performing an effective RCA. First, describe and explain the sequence of events that led to the problem discovery. This step should lead to establishing an accurate chronology of events. Next, clearly distinguish between the root cause, causal, and noncausal factors. Then, determine the sequence of events that most likely led to the problem. Finally, implement corrective measures.
Safety in dentistry is an integral part of daily operations. Developing a safety culture begins with the practice leaders. They must lead by example and establish a positive working environment. We can learn from the success of HROs, where there is strong leadership to take charge of creating and promoting a culture of safety, engaging staff, and incorporating continuous learning and improvement into the daily operations of everyone within the organization.
Doing so will foster good relationships and communication among everyone on the team, which is essential in building trust and promoting safety, and ultimately leading to less stress. Successful treatment outcomes, satisfied patients, and contented employees are some benefits of implementing a safe workplace culture. It is not a perception that can be imposed; instead, it must be shared and embraced by everyone involved.
Editor's note: This article appeared in the October 2022 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.
References
1. Kravarik J. Bacteria in dentist’s water sends 30 kids to hospital. CNN. October 12, 2016. Accessed August 2, 2022. https://www.cnn.com/2016/10/11/health/california-dental-water-bacteria/index.html
2. Bailey E, Tickle M, Campbell S. Patient safety in primary care dentistry: where are we now? Br Dent J. 2014;217(7):339-344. doi:10.1038/sj.bdj.2014.857
3. Safety culture—an overview. ScienceDirect. Accessed August 2, 2022. https://www.sciencedirect.com/topics/medicine-and-dentistry/safety-culture
4. Veazie S, Peterson K, Bourne D. Evidence brief: implementation of high reliability organization principles. Department of Veterans Affairs. 2019. Accessed August 2, 2022.
5. Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A framework for safe, reliable, and effective care. White paper. Institute for Healthcare Improvement (IHI) and Safe & Reliable Healthcare. 2017. Accessed August 2, 2022. https://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Safe-Reliable-Effective-Care.aspx
6. Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383. doi:10.2307/2666999
7. Boussat B, Seigneurin A, Giai J, Kamalanavin K, Labarère J, François P. Involvement in root cause analysis and patient safety culture among hospital care providers. J Patient Saf. 2021;17(8):e1194-e1201. doi:10.1097/PTS.0000000000000456
