Wrong tooth extraction: an examination of 'Never Event' data.
The NHS in England has identified several adverse incidents that involve patients, including operations done at the wrong site, as "never" events. We examined published data from the period April 2012 to October 2015 and found that "wrong tooth/teeth removed" is the most common "wrong site" event, and accounted for between 20% and 25% of wrong site surgery never events, and 6% - 9% of all "never" events. All "wrong tooth/teeth removed" events seem to have been reported only by hospitals or Community Trusts. It is important to find out how these events are recorded and to find ways to prevent them.
Consultant in Oral Medicine, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK. Electronic address: Mike.Pemberton@manchester.ac.uk.
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Pemberton
Consultant in Restorative Dentistry, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK.
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Ashley
Consultant in Oral Surgery, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK.
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Saksena
Divisional Director, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, M15 6FH, UK.
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Dickson
D004739:England; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D013222:State Medicine; D014081:Tooth Extraction
Never events; Patient safety; Wrong tooth