PMID- 37015101
OWN - NLM
STAT- MEDLINE
DCOM- 20230721
LR  - 20230902
IS  - 1549-8425 (Electronic)
IS  - 1549-8417 (Print)
IS  - 1549-8417 (Linking)
VI  - 19
IP  - 5
DP  - 2023 Aug 1
TI  - Identifying Contributing Factors Associated With Dental Adverse Events Through a 
      Pragmatic Electronic Health Record-Based Root Cause Analysis.
PG  - 305-312
LID - 10.1097/PTS.0000000000001122 [doi]
AB  - OBJECTIVE: This study assessed contributing factors associated with dental 
      adverse events (AEs). METHODS: Seven electronic health record-based triggers were 
      deployed identifying potential AEs at 2 dental institutions. From 4106 flagged 
      charts, 2 reviewers examined 439 charts selected randomly to identify and 
      classify AEs using our dental AE type and severity classification systems. Based 
      on information captured in the electronic health record, we analyzed harmful AEs 
      to assess potential contributing factors; harmful AEs were defined as those that 
      resulted in temporary moderate to severe harm, required hospitalization, or 
      resulted in permanent moderate to severe harm. We classified potential 
      contributing factors according to (1) who was involved (person), (2) what were 
      they doing (tasks), (3) what tools/technologies were they using 
      (tools/technologies), (4) where did the event take place (environment), (5) what 
      organizational conditions contributed to the event? (organization), (6) patient 
      (including parents), and (7) professional-professional collaboration. A blinded 
      panel of dental experts conducted a second review to confirm the presence of an 
      AE. RESULTS: Fifty-nine cases had 1 or more harmful AEs. Pain occurred most 
      frequently (27.1%), followed by nerve injury (16.9%), hard tissue injury (15.2%), 
      and soft tissue injury (15.2%). Forty percent of the cases were classified as 
      "temporary not moderate to severe harm." Person (training, supervision, and 
      fatigue) was the most common contributing factor (31.5%), followed by patient 
      (noncompliance, unsafe practices at home, low health literacy, 17.1%), and 
      professional-professional collaboration (15.3%). CONCLUSIONS: Pain was the most 
      common harmful AE identified. Person, patient, and professional-professional 
      collaboration were the most frequently assessed factors associated with harmful 
      AEs.
CI  - Copyright (c) 2023 Wolters Kluwer Health, Inc. All rights reserved.
FAU - Kalenderian, Elsbeth
AU  - Kalenderian E
FAU - Bangar, Suhasini
AU  - Bangar S
AD  - University of Texas Health Science Center at Houston, School of Dentistry, 
      Houston, Texas.
FAU - Yansane, Alfa
AU  - Yansane A
AD  - University of California at San Francisco School of Dentistry, San Francisco, 
      California.
FAU - Tran, Duong
AU  - Tran D
AD  - University of Texas Health Science Center at Houston, School of Dentistry, 
      Houston, Texas.
FAU - Sedlock, Emily
AU  - Sedlock E
AD  - University of Texas Health Science Center at Houston, School of Dentistry, 
      Houston, Texas.
FAU - Xiao, Yan
AU  - Xiao Y
AD  - University of Texas at Arlington, College of Nursing and Health Innovation, 
      Arlington, Texas.
FAU - Urata, Janelle
AU  - Urata J
AD  - University of California at San Francisco School of Dentistry, San Francisco, 
      California.
FAU - Olson, Greg
AU  - Olson G
AD  - University of Texas Health Science Center at Houston, School of Dentistry, 
      Houston, Texas.
FAU - Franklin, Amy
AU  - Franklin A
AD  - University of Texas Health Science Center at Houston, School of Biomedical 
      Informatics, Houston, Texas.
FAU - Kookal, Krishna
AU  - Kookal K
AD  - University of Texas Health Science Center at Houston, School of Dentistry, 
      Houston, Texas.
FAU - Ibarra-Noriega, Ana
AU  - Ibarra-Noriega A
AD  - University of Texas Health Science Center at Houston, School of Dentistry, 
      Houston, Texas.
FAU - Tungare, Sayali
AU  - Tungare S
AD  - University of Texas Health Science Center at Houston, School of Dentistry, 
      Houston, Texas.
FAU - Tokede, Oluwabunmi
AU  - Tokede O
AD  - University of Texas Health Science Center at Houston, School of Dentistry, 
      Houston, Texas.
FAU - Spallek, Heiko
AU  - Spallek H
AD  - University of Sydney School of Dentistry, Surry Hills, Australia.
FAU - White, Joel M
AU  - White JM
AD  - University of California at San Francisco School of Dentistry, San Francisco, 
      California.
FAU - Walji, Muhammad F
AU  - Walji MF
AD  - University of Texas Health Science Center at Houston, School of Dentistry, 
      Houston, Texas.
LA  - eng
GR  - R18 HS027268/HS/AHRQ HHS/United States
PT  - Journal Article
DEP - 20230407
PL  - United States
TA  - J Patient Saf
JT  - Journal of patient safety
JID - 101233393
SB  - IM
MH  - Humans
MH  - *Electronic Health Records
MH  - *Medical Errors
MH  - Root Cause Analysis
PMC - PMC10363220
MID - NIHMS1878926
COIS- The authors disclose no conflict of interest.
EDAT- 2023/04/05 06:00
MHDA- 2023/07/21 06:44
PMCR- 2024/08/01
CRDT- 2023/04/04 17:12
PHST- 2024/08/01 00:00 [pmc-release]
PHST- 2023/07/21 06:44 [medline]
PHST- 2023/04/05 06:00 [pubmed]
PHST- 2023/04/04 17:12 [entrez]
AID - 01209203-202308000-00004 [pii]
AID - 10.1097/PTS.0000000000001122 [doi]
PST - ppublish
SO  - J Patient Saf. 2023 Aug 1;19(5):305-312. doi: 10.1097/PTS.0000000000001122. Epub 
      2023 Apr 7.