Gestión del fracaso del tratamiento dental / Management of dental treatment failure

Desde la Bioética y empleando los principios de la calidad en salud y de la seguridad del paciente, se listan los diferentes argumentos que apoyan la necesidad de implementar de forma sólida los procedimientos de supervisión y auditoría interna en el centro dental para identificar, prevenir y manejar los diferentes niveles de fracaso que se dan en el ámbito terapéutico de la Odontología. (AU)

From bioethics and employing principles of quality in health and patients safety, different arguments are listed that support the need to solidly implement supervision and internal auditing procedures in the dental center to identify prevent and manage the different levels of failure that occur in the therapeutic field of dentistry. (AU)

Short Report. Audit of Conscious Sedation Provision in a Salaried Dental Service.

Clinical audit is a tool that may be used to improve the quality of care and outcomes for patients in a health care setting as well as a mechanism for clinicians to reflect on their performance. The audit described in this short report involved the collection and analysis of data related to the administration of 1,756 conscious sedations, categorised as standard techniques, by clinicians employed by an NHS Trust-based dental service during the year 2014. Data collected included gender, age and medical status of subject, the type of care delivered, the dose of drug administered and the quality of the achieved sedation and any sedation-related complications. This was the first time that a service-wide clinical audit had been undertaken with the objective of determining the safety and effectiveness of this aspect of care provision. Evaluation of the analysed data supported the perceived view that such care was being delivered satisfactorily. This on-going audit will collect data during year 2016 on the abandonment of clinical sessions, in which successful sedation had been achieved, due to the failure to obtain adequate local anaesthesia.

Reducing Harm in Healthcare Systems.

An understanding of the importance of causation of medical errors is important for determining strategies to reduce the harm that they can cause to patients. This paper discusses how dentistry can learn from medicine as well as other industries when developing approaches designed to deal with the causes of errors, rather than their outcomes.

Evidence Regarding Teaching and Assessment of Record-Keeping Skills in Training of Dental Students.

The aim of this study was to assess the literature on teaching and assessing dental students' record-keeping skills prior to qualification to practice independently as a dentist. A systematic literature review was performed using Ovid MEDLINE and SCOPUS. Keywords used in the search included dental, record, audit, education, and assessment. Electronic search results were screened for publications that targeted undergraduate dental training, related to a record-keeping education intervention, and were published in English and available in full text. Six studies met the inclusion and exclusion criteria. Data extraction and quality assessment were performed, and research findings were compared across the included studies. These six articles addressed the techniques used to teach and assess record-keeping skills in a pre-qualification context. The techniques included supervisor audits, peer audits, lectures, tutorials, research assignments, case reports, record-keeping templates, and checklists of required record components. The use of record audit as part of teaching and evaluation dominated these articles; it was used as the assessment method in five of the six studies. All methods of record-keeping training in studies published to date were found effective in improving student record-keeping skills. However, there was insufficient evidence to determine whether certain methods were more effective than others.

An audit into the reasons why treatment was not completed as planned under intravenous sedation in an adult oral surgery department, and the cost implications.

This audit aimed to identify the prevalence of, and reasons for failed intravenous conscious sedation in an adult oral surgery department, to develop recommendations to reduce such failures and to identify any cost implications. Data were collected prospectively for three months for all intravenous sedation appointments in the Oral Surgery department. Data were collected for 109 sedation appointments of which 83 were successful (76%). The failure rate (24%) was higher than the acceptable departmental failure rate (10%), and included reasons for failure that should have been avoided by a thorough patient assessment prior to treatment. Of the 26 failures, the most common reasons for failure were: cancellation: 8 patients (30.8%), failure to attend: 6 patients (23.1%), excessively late arrival of patient: 4 patients (15.4%) and failure to cannulate: 3 patients (11.6%). When sedation was unsuccessful, 13 of the 26 patients (50%) had their treatment successfully completed under local anaesthesia alone, 10 patients (38%) were rebooked for sedation and 3 patient. (12%) were rebooked for a general anaesthetic. Identifying and correcting the reasons for failure can result in vast savings in appointment time, clinical resources and cost. That 13 patients subsequently had their treatment completed under local anaesthesia alone opens the debate on how rigorous the patient assessment and allocation of sedation appointments was, and the potential to achieve savings.

A retrospective audit of population service access trends for cleft lip and cleft palate patients.

UNLABELLED: Population prevalence of orofacial clefts (OFCs) is well documented but the service utilisation patterns of these patients have received limited consideration. OBJECTIVE: To analyse 10-year trends in the utilisation of subsidised OFC related services in Australia. DESIGN: Retrospective audit of service utilisation and claims datasets. METHODS: Using state-wide hospital admission data, all persons treated for Cleft Palate Only (CPO) and Cleft Lip Only (CLO) as their primary diagnosis from 1999 to 2009 in Western Australia were included in the data frameset. Additionally, National Medicare out-of-hospital claims from 2003 to 2013 were added to the data frameset. The socioeconomic status and accessibility to services were analysed as effectors of service-mix such as age group, gender and geographic location. RESULTS: Of 721 in-hospital care episodes in Western Australia, 69% had CPO and 31% CLO as their principal diagnosis. Hospitalisations occurred from 0-69 years of age, but three quarters of all episodes occurred from 0-4 years of age (averaging one to two episodes per child). Whilst total hospitalisations were about four times higher for patients resident in high access areas, adjustment for population found the poorest 20% of the population having substantially lower hospital admission rates than the rest of the population. In Australia, claims for out-of-hospital cleft-related services varied between States. The overall pattern of out-of-hospital Medicare claims nationwide showed orthodontic services having the highest number of claims, followed by prosthodontic then oral surgical services. CONCLUSION: These data provide a picture of diverse service utilisation and leads to some interesting conclusions about geographic and economic access as well as cost-shifts between State and Commonwealth.

Audit of accuracy of clinical coding in oral surgery.

We aimed to study the accuracy of clinical coding within oral surgery and to identify ways in which it can be improved. We undertook did a multidisciplinary audit of a sample of 646 day case patients who had had oral surgery procedures between 2011 and 2012. We compared the codes given with their case notes and amended any discrepancies. The accuracy of coding was assessed for primary and secondary diagnoses and procedures, and for health resource groupings (HRGs). The financial impact of coding Subjectivity, Variability and Error (SVE) was assessed by reference to national tariffs. The audit resulted in 122 (19%) changes to primary diagnoses. The codes for primary procedures changed in 224 (35%) cases; 310 (48%) morbidities and complications had been missed, and 266 (41%) secondary procedures had been missed or were incorrect. This led to at least one change of coding in 496 (77%) patients, and to the HRG changes in 348 (54%) patients. The financial impact of this was £114 in lost revenue per patient. There is a high incidence of coding errors in oral surgery because of the large number of day cases, a lack of awareness by clinicians of coding issues, and because clinical coders are not always familiar with the large number of highly specialised abbreviations used. Accuracy of coding can be improved through the use of a well-designed proforma, and standards can be maintained by the use of an ongoing data quality assurance programme.

A auditoria odontológica nos serviços de saúde suplementar / Dental auditing in supplementary health care services

O sistema de saúde no Brasil vem sofrendo grandes transformações. Em virtude da saúde pública não ter condições de atender as necessidades da população, junto ao baixo poder aquisitivo da população para custear de forma direta seus tratamentos, foi institucionalizado o sistema de saúde suplementar, que complementa o serviço de saúde público. Com a crise no mercado odontológico provocada pelo excesso de profissionais, muitos cirurgiões-dentistas,passaram a trabalhar em parceria com as operadoras de planos de saúde (OPS), na expectativa de aumentar a clientela. Essa parceria promove reorganização acelerada e irreversível do setor, em que a relação entre paciente e cirurgião-dentista é intermediada pela OPS. Objetivo: demonstrar por meio de atualização de literatura a importância da auditoria nos serviços de saúde bucal oferecidos pelas OPS, destacando o papel do auditor técnico como gestor de saúde, exprimindo sua função educadora e não fiscalizadora ou punitiva. Considerações finais: devido ao crescimento das OPS, regulação do setor através da lei 9656/98 e código de defesa do consumidoras OPS passaram a desenvolver instrumentos de avaliação da qualidade dos serviços prestados, dentre eles, a auditoria odontológica. Entretanto, este novo modelo de exercer a prática odontológica, tem trazido conflitos para os profissionais que desconhecem a importância do auditor nos serviços de saúde bucal. As ações dos serviços de auditoria são pautadas por princípios éticos-legais e baseadas em evidências que fundamentam a prática odontológica, além disso representa segurança adicional para o beneficiário através do controle de qualidade a que seu tratamento é submetido...

The health care system in Brazil is undergoing large transformations. Due to the public health care system's inability to attend to the needs of the whole population, together with the general population's inability to pay for needed treatment out of pocket, the supplementary health care system was created to augment the public system. With the crisis in the dental industry caused by the excess of dental professionals, many dentists began partnering with health care plan operators (HPO) with the hope of expanding their clientele. These partnerships encourage an accelerated and irreversible reorganization in the industry, where the relationship between patient and dentist is mediated by the HPO. Objective: to demonstrate via a review of the most recent literature the importance of the practice of auditing the oral-health services offered by the HPOs, highlighting the role of the technical auditor as health manager, focusing on its educational function and not fiscal or punitive. Final remarks: due to the growth of the HPOs, regulation of the sector via the law 9656/98 and the consumer-defense code, the HPOs started to develop tools to evaluate the quality of the performed services, amongst them, the dental audit. Nevertheless, this new model for the dental industry has given rise to problems for dental professionals that are unaware of the importance of the auditor in relation to oral health services. The actions of the auditing services are regulated by legal and ethical principles and based on fundamental data from dental practice. Beyond that, they add additional assurance for patients via quality control and ensuring their treatment is submitted...

An audit of orthodontic treatment eligibility among new patients referred to a Health Service Executive orthodontic referral centre.

AIM: The aim of this audit was to evaluate orthodontic treatment eligibility among new patients referred for assessment from primary dental care clinics in the Health Service Executive (HSE) South region to a HSE orthodontic referral centre. METHOD: A data collection form was designed and applied prospectively to consecutive new patient referrals who attended diagnostic clinics at the Orthodontic Unit, Cork University Dental School and Hospital, between October 2011 and February 2012. Orthodontic treatment eligibility was based on guidelines introduced by the HSE in 2007. RESULTS: Data on 291 patients (147 males and 144 females) with a mean age of 11.6 years (SD +/- 2.4 years; range 8-19 years) were evaluated. Of the 83 (29%) patients eligible for orthodontic treatment under the guidelines, the most commonly diagnosed malocclusion traits were a crossbite with greater than 2 mm discrepancy between retruded contact position and intercuspal position (24 patients), followed by an overjet greater than 9 mm (21 patients). CONCLUSIONS: A total of 29% of new patient referrals were deemed eligible for orthodontic treatment under HSE eligibility guidelines introduced in 2007. Reduction of new patient referrals not eligible for treatment, under these guidelines, is required to enable more efficient use of resources.

Audit of the Health Service Executive orthodontic referral pathway between 2009 and 2011 in the Dublin Mid-Leinster region.

An audit was undertaken in 2009 to determine the success of the new national orthodontic referral protocol introduced to the Health Service Executive (HSE) in 2007 and operated in the Dublin Mid-Leinster HSE region. It was repeated in 2011 to determine if the HSE austerity measures have had a bearing on the orthodontic service performance in the Dublin Mid-Leinster HSE region. The audit also measured the success of referring practitioners in identifying the correct Index of Orthodontic Treatment Need (IOTN) classification of the patient. In the 2011 audit, the figures were broken down to identify the occlusal variables that caused dental practitioners most difficulties in identification. The audit demonstrates a good referral to assessment timeframe in 2009 (85-80% compliance for IOTN 5 and 4 within three to six months, respectively), which deteriorates significantly in 2011 (26-4% for IOTN 5 and 4 within three to six months, respectively). The ability of dentists to identify the correct IOTN classification was better in 2009 (60% correct) compared to 2011 (51% correct), but both figures fell below the audit standard of 75% of referrals with correct IOTN classifications. The IOTN occlusal dental health components most readily identified by referring practitioners and meeting audit standards were 5a (overjet >9mm), 5i (impacted teeth) and 5h (extensive hypodontia). The remaining occlusal dental health components in the HSE IOTN fell below the audit standard. The audit clearly identifies a requirement for a continued educational effort to maintain the HSE IOTN skill base in primary care, and a need for additional resources to manage the demand for orthodontic assessments.

Development of an evidence-based prosthodontic record: an action research study.

This study sought to develop a database in the field of removable prosthodontics by using a participatory action research method. Data collection consisted of a comprehensive literature review, focus-group discussions, and interviews. Applying action research methods ensures consideration of the needs, perspectives, and expertise of academia in the design and implementation of an evidence/ research-based patient record, and academic educators are well placed to conduct such research.

A national audit of Australian dental practice distribution: do all Australians get a fair deal?

Australia is the sixth biggest (by area) country in the world, having a total area of about 7.5 million km(2) (3 million square miles). This study located every dental practice in the country (private and public) and mapped these practices against population. The total population of Australia (21.5 million) is distributed across 8,529 suburbs. On average about one-third of the population from each State lives in suburbs without practices and 46% live in suburbs with one to five dentists. Of those living within the study frameset, 86.6% live within 5 km of a private practice and 84.4% live within 10 km of a government practice. Australia's dental practices are distributed in a very uneven fashion across its vast area. Three-quarters of suburbs have no dental practice and over one-third of the population live in these suburbs. This research clearly identified that in a vast and uneven socio-geographically distributed country, service planning, if left to market forces, will end with a practice distribution that is fixed by economic drivers of scale and not that of disease burden. A more population health-driven approach to future design and construction of government safety net services is needed to address these disparities.