Where did that dental bur go? Patient Safety Lessons from a Dental Teaching Hospital
DOI:
https://doi.org/10.11606/issn.2317-2770.v29i1e-224159Keywords:
Patient safety, Near-miss, Dental teaching clinics, Ingested burAbstract
Introduction: Ingested or aspirated dental burs have been reported in the literature. These events are akin to medical errors that can potentially cause patient morbidity or mortality and must be examined in the larger context of maintaining patient safety in dental settings. Case report: This work presents a case of an ingested bur and a near-miss event of a bur detached from a high-speed dental handpiece. Both cases occurred during the management of patients by students in a dental school setting. Conclusion: These cases are presented through the lens of patient safety. Conclusions are made on how organizational policies and curricula change can prevent such errors in the dental clinical training environment and mitigate patient morbidity or mortality.
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Lynch C, Burke F. Quality of root canal fillings performed by undergraduate dental students on single‐rooted teeth. Eur J Dent Educ. 2006;10(2):67-72. DOI: https://doi.org/10.1111/j.1600-0579.2006.00397.x
Marchan SM. Knowledge and perceptions of patient safety and patient safety culture in a dental school: a qualitative study [thesis]. Indianapolis, USA: American College of Education; 2023.
Abusamaan M, Giannobile WV, Jhawar P, Gunaratnam NT. Swallowed and aspirated dental prostheses and instruments in clinical dental practice: a report of five cases and a proposed management algorithm. J Am Dent Assoc. 2014;145(5):459-63. DOI: https://doi.org/10.14219/jada.2013.552014;145(5):459-63
Rodziewicz TL, Hipskind JE. Medical error prevention. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019. [Accessed 2023 Dec. 28]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK499956/
Reason J. Human error: models and management. Br Med J. 2000;320(7237):768-70. DOI: https://doi.org/10.1136/bmj.320.7237.768
Rodziewicz TL, Houseman B, Hipskind JE. Medical error reduction and prevention. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018. [Accessed 2023 Dec. 28]. https://europepmc.org/article/NBK/nbk499956
Voskanyan Y, Shikina I, Kidalov F, Musaeva S, Davidov D. Latent failures of the individual human behavior as a root cause of medical errors. In: Antipova T. (eds) Advances in digital science. ICADS 2021. Advances in intelligent systems and computing. Springer, Cham. 2021;1352:222-34. DOI: https://doi.org/10.1007/978-3-030-71782-7_20
Yadav RK, Yadav HK, Chandra A, Yadav S, Verma P, Shakya VK. Accidental aspiration/ingestion of foreign bodies in dentistry: a clinical and legal perspective. Nat J Maxillo Sur. 2015;6(2):144-51. DOI: https://doi.org/0.4103/0975-5950.183855
Iovino P, Di Sarno A, De Caro V, Mazzei C, Santonicola A, Bruno V. Screwdriver aspiration during oral procedures: a lesson for dentists and gastroenterologists. Prosthesis. 2019;1(1):61-8. DOI: https://www.mdpi.com/2673-1592/1/1/8#
Hou R, Zhou H, Hu K, Ding Y, Yang X, Xu G, et al. Thorough documentation of the accidental aspiration and ingestion of foreign objects during dental procedure is necessary: review and analysis of 617 cases. Head Face Med. 2016;12:1-8. DOI: https://doi.org/10.1186/s13005-016-0120-2
Tiwana KK, Morton T, Tiwana PS. Aspiration and ingestion in dental practice: a 10-year institutional review. J Am Dent Assoc. 2004;135(9):1287-91. DOI: https://doi.org/10.14219/jada.archive.2004.0404
Kim E, Noh W, Panchal N. Mortality from an aspiration of dental crown during extraction. Gerodontology. 2017;34(4):498-500. DOI: https://doi.org/10.1111/ger.12288
Little D. Handpieces and burs: the cutting edge [Internet]. Dentsply Styls. 2009. [Accessed 2023 Dec. 28]. Available at: Handpieces and Burs: The Cutting Edge (stylusatc.com)
Saksena A, Pemberton MN, Shaw A, Dickson S, Ashley MP. Preventing wrong tooth extraction: experience in development and implementation of an outpatient safety checklist. Br Dent J. 2014;217(7):357-62. DOI: https://doi.org/10.1038/sj.bdj.2014.860
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