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A blog by Steve Wake discussing Never Events, and how the change in definition effects dentistry.
By Steve Wake
What is the definition of a Never Event?
According to NHS improvement, a Never Events is:
“incidents with ‘the potential to cause serious patient harm or death’ that are ‘wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers’”
This was an amended definition following a working group of multidisciplinary and multi-stakeholder panel. This was a change from:
“The NHS defines Never Events as ‘serious largely preventable patient safety incidents that should not occur if relevant preventative measures have been put in place’”
The latter definition was, to my mind a more elegant and simple definition which anyone would understand as a Never Event. The new definition has resulted in removing certain procedures from the Never Events list.
Why should this matter?
The result of the change in definition is that the removal of the wrong tooth is now not included in the Never Events list. The reason is because the barriers in place to prevent occurrences of wrong tooth removal are insufficient to meet the Never Event definition.
So because dentistry hasn’t put in place barriers to prevent this, arguably, serious harm, the result is that it’s easier to remove it from the list.
In my opinion this is simply a case of tinkering with wording whilst doing nothing to stop these incidences from happening. There are plenty of these incidences happening and I think it devalues the role of dentistry and how the NHS sees the importance and perhaps the impact of problems with the mouth. Although, we pay an NHS charge for our dental treatments it seems that the removal of the wrong tooth is now thought of by the British Dental Journal as a “dentistry-specific mishap”, which I think rather underplays the issue and ignores effect that this mishap can have on people’s lives and their mental health. Not to mention their bank balance when they have to pay for a dental implant and maintenance for life!
I would be interested to hear your views on this, particularly if you have had the wrong tooth removed. I assure you that we will treat any claim of this type as having been a Never Event.