WHO surgical safety checklist training: An alternative approach to training in local safety standards for invasive procedures.

BACKGROUND: Despite efforts to promote the effective use of the WHO surgical safety checklist, wrong tooth extractions have continued to occur within dentistry. METHOD: A training initiative combined methods of teaching comprising of a presentation, video and simulation to deliver LocSSIP training at an Oral Surgery Department of a UK dental hospital. Participant feedback was analysed to determine their perception of using combined methods to deliver the training. RESULT: Overall feedback was very positive with regard to relevance of the training, and its ability to meet the learning needs of all participants. Participants advocated that there should be regular re-training and incorporation of this training into the local induction programme. Almost About 94% of staff members Strongly Agreed or Agreed that they would recommend this format of training to other departments. CONCLUSION: Effective training is essential to maintain safe clinical practice within health care, and training methods that are inclusive of various learning styles are well received.

Systematic review of benefits or harms of routine anaesthetist-inserted throat packs in adults: practice recommendations for inserting and counting throat packs: An evidence-based consensus statement by the Difficult Airway Society (DAS), the British Association of Oral and Maxillofacial Surgery (BAOMS) and the British Association of Otorhinolaryngology, Head and Neck Surgery (ENT-UK).

Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.

Wrong tooth extraction: further analysis of "never event" data.

The NHS in England requires the reporting of defined "never events" that are directly related to patients' safety. Analysis of data from 2012-2015 has been published previously in this journal. An examination of continuing data from 2015-2019 shows that "wrong tooth/teeth removed" has not reduced in frequency and it still remains a common "wrong-site surgery" event accounting for between 16% and 24% of wrong-site surgery never events and 7%-10% of all never events reported. Hospitals and community Trusts remain the main source of such reports, although some now originate from primary-care-based dental settings. Further efforts have focused on prevention, and the implementation of existing measures to reduce the risk of wrong tooth extraction, is warranted.

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.