A Culture of Safety: Why Reinvent the Wheel?

Abstract

No patient should die in the dental office. With few exceptions, deep sedation and general anesthesia for dentistry is performed in the office-based environment on patients without significant medical compromise while moderate sedation is provided for a wider range of patients. Those patients with undue risks are routinely referred to a hospital or surgery center, so patient deaths in the dental office should be exceptionally rare. Yet in mid-July, a story involving the death of a dental patient circulated throughout the national news, sadly marking the second such report that month. Consistent with most initial news releases covering these types of incidents, the article shared only sparse information centered on secondand third-hand accounts, leading to ample speculation among professionals and the public alike. Little could be gained in terms of appreciating any likely causes or contributing factors. It was not even clear if the anesthesia provider was a dentist, physician, or nurse. Notably, had either of these tragedies occurred in a hospital, the stories would almost certainly not have been featured in the news. Although the true occurrence rate of substantial morbidity and mortality tied to sedation or general anesthesia in the dental office is virtually impossible to ascertain accurately, conservative estimates approach 1 event every 6 weeks based on historical information derived from closed claims databases. However, the rate is likely higher, perhaps averaging more than 1 event per month, as such databases fail to encompass all providers utilizing sedation and general anesthesia for dental treatment. Simply put, this is an ongoing issue that rests squarely on all our shoulders, even if a number of these deaths occur while the patient is under the care of a physician or nurse. Typically, discussion of such a delicate subject is fraught with potential political and legal implications. There is no question that the presence of conflicts of interest, both real and perceived, often muddy the waters further. My intent is not to discuss the more controversial issues, like training requirements, licensure, or supervision (ie, who should be permitted to do what), but rather to draw attention to the gaping flaws within our current system that should provide professional oversight and guidance, ultimately to effect continuing improvement. The concept of evidence-based medicine has been around for quite some time, originating in the 19th century. Adoption and integration into dentistry has been slow, although momentum is undeniable. Sadly, it is almost impossible to apply an evidence-based approach effectively to the ongoing issues of sedation and general anesthesia-related morbidity and mortality in dentistry due to the absence of comprehensive data. Dentistry lacks a clear concise accounting of not only the numerator (ie, number of adverse anesthesia outcomes) but also the overall denominator (ie, how many cases each of moderate sedation, deep sedation, and general anesthesia are performed per year). Furthermore, state dental boards effectively discourage disclosure of relevant information from cases involving poor outcomes. Although the reasons are multifactorial, compounding this problem is the relative isolation of the typical dental practice that simply does not lend itself well to self-reporting and therefore ‘‘Big Data.’’ Without data access, it is virtually impossible for providers to perform root cause analysis effectively in order to identify and address any recurrent underlying issues. If we don’t know what’s broken, how can we fix it? Throughout the years, the general field of anesthesiology has successfully borrowed many safety optimizing approaches from the aviation industry, which has been a leader in safety analysis. Commonplace anesthesiology protocols such as preoperative checklists, emergency response flowcharts, and simulation all have roots stemming from within aviation. Even the terms used to describe the stages of anesthesia often evoke thoughts related to flying (induction/takeoff; maintenance/cruising; and emergence/landing). In the early years, flying was considered relatively unsafe, and as commercial aviation grew, incidents were occurring with increased regularity and beginning to erode public trust. The US airline industry responded with a multifaceted approach that included strict regulatory oversight from the Federal Aviation Administration (FAA) along with the aforementioned safety measures, all primarily guided by data. The safety initiatives implemented by the aviation industry significantly increased air travel safety to the point that safety concerns during domestic commercial flights are statistically incredibly rare events. Importantly, the FAA has continued to innovate despite their successes. Prior to 2015, more traditional regulatory methods, such as fines and civil penalties, were used to ensure compliance. However, the FAA changed course in 2015 after concluding that the strict use of punitive approaches promoted a culture that disincentivized self-reporting and disclosure of potentially negative information. They now stress a ‘‘collaborative problem-solving approach (ie, engagement, rootcause analysis, transparency, and information exchange)’’ built upon a culture where self-reporting is Anesth Prog 68:131–132 2021 j DOI 10.2344/anpr-68-03-14 2021 by the American Dental Society of Anesthesiology