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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 41-46

Evaluation of incidence and reasons of wrong side dental surgery in central Maharashtra


1 Department of Oral and Maxillofacial Surgery, RDC, Pravara Rural Dental College and Hospital, PIMS, Loni, Maharashtra, India
2 Department of Periodontics, RDC, Pravara Rural Dental College and Hospital, PIMS, Loni, Maharashtra, India
3 Department of Periodontology, Jamia Millia Islamia, Faculty of Dentistry, New Delhi, India
4 Department of Public Health Dentistry, RDC, Pravara Rural Dental College and Hospital, PIMS, Loni, Maharashtra, India

Date of Submission29-Nov-2020
Date of Decision14-Dec-2020
Date of Acceptance11-Jun-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
Harish Saluja
Department of Oral and Maxillofacial Surgery, Pravara Rural Dental College and Hospital, PIMS, Loni, Ahmednagar, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_60_20

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  Abstract 


Background: Wrong side surgery (WSS) has gained national attention now. These errors are as terrifying as these involve patients who have undergone surgery on the wrong body part, undergone wrong procedure, or had a procedure intended for another patient. Materials and Methods: A questionnaire survey dealing with WSS was prepared, and 300 dental professionals were randomly mailed. All responses were gathered in Excel and analyzed using software SPSS version 19. Results: In the present study, the 213 dental professionals working in dental colleges in Ahmednagar gave the feedback, 29 of them had attempted WSS. The study was carried out on in two groups. The first comprised students undergoing bachelors in dentistry and other group was with professionals completed their bachelors in dentistry. The results were highly significant in those undergoing bachelors in dentistry with more incidence of WSS. Conclusion: The Joint Commission on Accreditation of Healthcare Organizations (JCAHOs) found WSSs as the 3rd highest event. The data are definitely more than that recorded in literature but due to fear clutched at the throat people do not disclose their mistakes though it happens.

Keywords: Dental procedures, dentistry, incidence, wrong side surgery


How to cite this article:
Saluja H, Sachdeva S, Chawla K, Mohammadi SN. Evaluation of incidence and reasons of wrong side dental surgery in central Maharashtra. J Head Neck Physicians Surg 2021;9:41-6

How to cite this URL:
Saluja H, Sachdeva S, Chawla K, Mohammadi SN. Evaluation of incidence and reasons of wrong side dental surgery in central Maharashtra. J Head Neck Physicians Surg [serial online] 2021 [cited 2021 Dec 5];9:41-6. Available from: https://www.jhnps.org/text.asp?2021/9/1/41/319745




  Introduction Top


Wrong-site surgery has captured attention of nation and prompted mounting efforts to prevent these mishappenings. The term wrong site surgery typically encompasses surgery on the wrong person, the wrong organ, limb, wrong vertebral level, or wrong side or tooth.[1],[2] Although the problem seems to be rare, the incidence of these errors seems difficult to estimate because real values not disclosed due to fear among professionals.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) found wrong side surgeries (WSSs) to be the third-highest-ranking event.[3] As per data from the literature, a branch of medicine (Orthopaedics) and dentistry, as a whole, are the most common ones where WSS occur most often. As per Joint Commission for Accreditation of Hospitals (JCAHO), Wrong-site surgery is most prevalent in orthopedic and pediatric procedures (41% of the total reported).[3] The next three specialties most commonly represented are 9 general surgery (20%), neurosurgery (14%), and urological surgery (11%). The remainder was accounted for by dental, oral, and maxillofacial procedures; cardiovascular and thoracic surgery; and otorhinolaryngology and ophthalmology.[3]

Because of seemingly, more number of cases seen in dentistry, a study was carried out in the Department of Oral and maxillofacial surgery, in which 300 dental professional volunteers were interviewed, and questionnaire was prepared for dental students undergoing bachelors' degree and staff. The data were collected and recorded.

Procedures on wrong or incorrect anatomical site are perceived as being relatively rare. They can be a devastating event both for patients and doctors. Evidence from the United Kingdom and North America suggests that wrong site, wrong procedure, and wrong patient events occur very commonly than we can think.[3] Furthermore, their incidence may be increasing due to increase in the volume and complexity of procedures undertaken in order to cope with increasing demands on the system.

An analysis of data from 22 medical malpractice insurers, representing 110,000 physicians, identified 331 claims for wrong-site surgery throughout 10 years. These claims comprised 1.8% of orthopedic surgical claims.[4] The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also performed a root cause analysis of 126 cases reported to them.[5] Surgery on the wrong patient occurred in 13% of cases, using the wrong procedure in 11%, and on the wrong body part or site in 76%. Possible risk factors identified included emergency operations, unusual time pressures to start or complete the procedure, and involvement of multiple surgeons or multiple procedures in a single surgical visit. In 2003, the JCAHO convened a national summit to review the problem. Based on the summit's recommendations, it promulgated the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.[6] [Table 1] depicts NHS Litigation authority information on claims involving surgery on the wrong body part or patient or anatomical site 1995–2007 (data obtained 31/03/08 courtesy of the NHS Litigation Authority).[7]
Table 1: Depicts the specialty from various fields of medicine and dentistry with reported incidence of number of wrong side surgeries (%)

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  Materials and Methods Top


A cross-sectional descriptive study was conducted by the department of oral and maxillofacial surgery for evaluating previous experiences of wrong tooth extraction or site surgery after taking ethical clearance from the research cell. A self-administered questionnaire was prepared and mailed to 300 dental professionals including staff and dental interns out of which 213 participants responded. The questionnaire was pilot tested, and the validity of the questionnaire was found appropriate in terms of its design and content. Reliability of questionnaire was measured and Chronbach's alpha was 0.71. The study was carried out for a period of 1 year from July 2018 to June 2019. All responses were gathered on excel sheet and analyzed for frequency and cumulative percentages which were calculated using SPSS version 19 (SPSS Inc., Chicago, IL, USA). A questionnaire was set for evaluation which included set of questions mentioned below:

  1. Whether have you performed any wrong side/site/tooth/surgery procedure?


  2. □ Yes

    □ No.

  3. At what stage of your career?


    1. Intern
    2. Dental professional completed with bachelor's degree.


  4. Number of wrong side/site/tooth/surgery procedure?


    1. One
    2. More than one.


  5. Whether you disclosed/accepted your mistake to patient/staff?


    1. Yes
    2. No.


  6. What could be the reason for such incident?


  1. Stress/tension in operator's mind
  2. Overload of work
  3. Miscommunication/improper notes
  4. Any other.



  Results Top


In the present study, the cumulative value out of 213 participants was 13.6% who did WSS. The frequency table showed that WSS was conducted in 97.2% in Group 1 which comprised students and in Group 2, WSS incidence was 2.8% who were already learned professionals and completed their bachelor's degree. [Table 2] depicts the stage of profession, in which WSS was performed. The WSS was significantly more in Group 1.
Table 2: Stage of profession

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Out of 13.6% dental professionals who committed WSS, mistakes were disclosed by only 9.4% and rest 4.2% did not disclose their mistakes. [Table 3] depicts the valid percentages of professionals who disclosed the WSS.

The inferences drawn from the [Graph 1] depicts the frequency of WSS which were mostly because of miscommunication followed by overload on dental professionals and stress. There could be other reasons too which are not mentioned in questionnaire.
Table 3: Professionals who disclosed wrong side surgeries in front of patients or relatives

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The professionals who did one time WSS were 10.8%, and to our surprise, there were 2.8% participants who did WSS for more than one time in spite of facing one incident they repeated the mistake again. [Graph 2] depicts number of WSS faced during lifetime.




  Discussion Top


In the present study, the dental professionals who were undergoing the bachelor's degree WSS was conducted in 97.2% in Group 1 and in Group 2, WSS incidence was 2.8% who were already learned. Hence, it can be inferred that learned professional's committed significantly less mistakes. There were hardly any studies who worked on the mistakes occurred at what age of profession to compare the results.

The Joint Commission is an independent, nonprofit making organization responsible for accrediting and certifying many of the health care organizations and programs in the United States [Refer [Figure 1]. In the United States, wrong-site surgery is classed as a “sentinel event” that is reported voluntarily to the Joint Commission on Accreditation of Health Care Organizations, which maintains a database and analysis of such events. Information about sentinel events is disseminated by the joint commission through “Sentinel Event Alerts” so that health-care providers learn from and avoid repetitions.[5],[6] Though the incidence in repetition of WSS was 2.8%, it might be more also but due to fear clutching them they might not have disclosed.
Figure 1: Percentage of wrong side surgery in various fields of medicine

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There are innumerous reasons causing wrong site, side, or wrong patient surgery few are listed in [Figure 2].
Figure 2: Reason of wrong side surgery

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In the majority of wrong-site surgery cases, communication error failures involving the surgical team members or between members of the team, the patient, and his or her family members could be implicated. The present study has inferred overload of work and miscommunication as major reasons for wrong side procedure. Many studies and the one by JCAHO 2005 included that root cause of WSS was communication problem which had similar results as that of our study but an equal contributing factor in our study is overload of work.[8] Both accounted same incidence of 41.3% of total wrong side surgeries. The difference might be because of error in sampling size, and focus of sampling population was different.

The protocol

On May 9, 2003, a summit was held under the auspices of JCAHO to discuss wrong-site surgery and agree on a “universal protocol” for preventing wrong-site, wrong-procedure, and wrong-person surgery.[9]

Protocol for dentistry

Treatment of a wrong tooth occurs with surprisingly high frequency and in most cases, it is preventable by taking the underlying precautions [Refer [Figure 3]:[9]
Figure 3: The protocol and three main checklist headings

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  1. Always include the checklist mentioned beneath document and why such a treatment is warranted
  2. Double check the tooth number


    • Always confirm the correct tooth with your patient and check the referral form and radiographs
    • Improve communication between the referring dentist and the surgeon and make a standardized referring system for all the dentists to avoid confusion
    • Examine any appliance sent with the patient to be sure it matches up with the tooth to be treated
    • Insist on the name and number of the tooth/teeth
    • Check for missing teeth in site adjacent to that of extraction to shift to avoid misnumbered
    • Contact the referring dentist-Don't assume.


  3. Confirm that you have the patient's informed consent for the specific tooth or teeth
  4. Slow down and be careful
  5. Be proactive if something goes wrong.


Identify any wrong tooth treatment as soon as possible to improve the patient's clinical outcome and reduce your legal liability, simultaneous offer of a well-reasoned solution (e.g., implant, orthodontic movement, or bridge), and a discussion regarding cost deferral.

  • Don't leave it up to the patient to try to find a solution. For specialists practicing in the field of dentistry, a committee comprising attending doctors in the Division of Oral and Maxillofacial Surgery reviewed the information, identified factors contributing to the errors, and developed the following clinical guidelines for preventing erroneous extraction:[10]
  • Include in the written order for tooth extraction a brief description of the condition of the tooth that is to be extracted and of the adjacent teeth if necessary
  • Inform the patient (or the parent or guardian in the case of a child) about the position of the tooth that is going to be extracted and the reason why it should be extracted
  • The operator should verify the order with the patient (or the parent or guardian) and carefully identify the position of the tooth in question to the patient (or the parent or guardian)
  • Do not hesitate to communicate verbally with the referring dentist whenever it is thought necessary
  • Check the tooth position before and after the application of the forceps.


Cases where wrong side surgery can occur in dentistry

  • Communication errors between the dentist and the specialist
  • Errors in the following tooth numbering systems
  • Extraction of impacted teeth even if the tooth is planned to be retained
  • Accidental extractions of adjacent teeth
  • Extraction of a carious tooth by other dentist when the same tooth was planned for advanced restorative treatment
  • Extraction of an adjacent carious tooth if the tooth requested for extraction is not


Visible/submerged/covered by soft tissue

  • Extraction of root pieces when multiple root stumps are present
  • Counting errors when one tooth is missing
  • Recognizing partially erupted teeth as impacted
  • Extraction of upper and lower teeth as a general practice of doing so, even when only one is requested for extraction at that time
  • Extraction of an otherwise restorable tooth because of difference in opinions.


The true incidence of wrong-site errors is difficult to define accurately owing to underreporting, the lack of a standard definition of what constitutes wrong-site surgery, and the inclusion of near misses in some estimates. Furthermore, some studies include only those cases which ended in litigation.[6] One could assume that these comprise only the most serious or damaging cases, resulting in an underestimate of the true incidence of wrong-site surgery. The data are subject to variation with trends in litigation and the reporting of incidents will be much more, but due to fear by professionals, the data reported might be 10%–15% more than that reported.

Like North American Spine Society (NASS), some organization should be made in India also to develop protocol to prevent WSS. NASS was the first professional organizations in the United States to prevent wrong side surgery. They have developed a Campaign “SMaX” (Sign, Mark, and X-ray). Patient diagnosis diagram is one of the agenda of this campaign that is given to the patient by the surgeon during the preoperative discussion. The patient can share this document with other health-care providers and also bring this form at the time of surgery. NASS now endorses the Joint Commission universal protocol, as well.[11]


  Conclusion Top


Wrong-site surgery errors must be viewed in the context of human limitations, not as failings of individuals. Incidence of errors is a sign of breakdown in the system and teamwork. Disciplinary action will not prevent these system errors. Changing the culture from culpability to one founded upon human factors engineering[12] group dynamics[13] and the psychology of errors will separate the mistake from the blame. Studying the psychology behind the errors will more effectively identify factors that can optimize work systems, reduce stress, improve performance, prevent or detect system breakdowns before they occur, and thereby improve patient safety. Hence, it is now inevitable to get the correct data and statistics on WSS in dentistry and set guidelines to avoid such cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Ethical approval

The permission was obtained from the Institutional Ethics Committee before starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
  References Top

1.
Mulloy DF, Hughes RG. Patient Safety and Quality: An Evidence-Based Handbook 350 for Nurses. Available from: https://www.ahrq.gov/qual/nurseshdbk/nurseshdbk.pdf. [Last accessed on 2011 Dec 16].  Back to cited text no. 1
    
2.
Chassin MR, Loeb JM. High- reliability health care: getting there from here. The Milbank Quarterly.2013;91:459-90.  Back to cited text no. 2
    
3.
Joint Commission on Accreditation of Healthcare Organizations. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery [JCAHO News Release]; July 21, 2003. Available from: https://www.jcaho.org/accredited+organizations/patient+safety/universal+protocol/wssuniversal+protocol.htm. [Last accessed 2020 Dec 18].  Back to cited text no. 3
    
4.
American Academy of Orthopaedic Surgeons Council on Education. Report of the Task Force on Wrong-Site Surgery. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1998. Available from: https://www.aaos.org/wordhtml/meded/tasksite.htm. [Last accessed 2020 Nov 08].  Back to cited text no. 4
    
5.
Joint Commission on Accreditation of Healthcare Organizations. A Follow-Up Review of Wrong Site Surgery. Sentinel Event Alert. December 5, 2001: Issue 24. Available from: https://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_24.htm. [Last accessed 2019 Dec 14].  Back to cited text no. 5
    
6.
Joint Commission on Accreditation of Healthcare Organizations. Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery [JCAHO News Release]. July 21, 2003. Available from: https://www.jcaho.org/accredited+organizations/patient+safety/universal+protocol/wss_universal+protocol.htm. [Last accessed 2020 Jan 04].  Back to cited text no. 6
    
7.
No Authors Listed. Chief Medical Officer. On the State of Public Health: Annual Report of Thechief Medical Officer 2007. Chapter 4: While you Were Sleeping: Making Surgery Safer. Department of Health. Available from: http://www.dh.gov.uk/en/Publicationandstatistics/Publications/AnnualReports/DH_086176. [Last accessed on 2008 Jul 15].  Back to cited text no. 7
    
8.
Dagi TF, Berguer R, Moore S, Reines HD. Preventable errors in the operating room – Part 2: Retained foreign objects, sharps injuries, and wrong site surgery. Curr Probl Surg 2007;44:352-81.  Back to cited text no. 8
    
9.
Preventing Wrong Tooth Extraction. Available from: http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/CON_ID_002303. [Last accessed 2020 Jly 04].  Back to cited text no. 9
    
10.
Chang HH, Lee JJ, Cheng SJ, Yang PJ, Hahn LJ, Kuo YS, et al. Effectiveness of an educational program in reducing the incidence of wrong-site tooth extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:288-94.  Back to cited text no. 10
    
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Authority PP. Doing the right things to correct Wrong Site Surgery. PA PSRS Patient Saf Advis. 2007;4:29-32.  Back to cited text no. 11
    
12.
Carayon P, Schultz K, Hundt AS. Righting wrong site surgery. Jt Comm J Qual Saf 2004;30:405-10.  Back to cited text no. 12
    
13.
Henriksen K. Organizational silence and hidden threats to patient safety. Health Serv Res 2006;41:1539-54.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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