An analysis of dental adverse events in the Veterans Health Administration

Background

Information on patient safety in dentistry is limited. Few dentists work in a place with incident reporting, thus, studying safety events is a challenge. The authors analyzed dental adverse events that rose to the level of root cause analyses that occurred in the Veterans Health Administration (VHA). The authors aimed to identify the most common adverse events, their causes, and recommended actions.

Methods

The authors searched the VHA national database for reports of dental adverse events from January 1, 2021, through November 18, 2024. Reports were included if they occurred in the dental clinic, operating room, or care facility and were related to a procedure or dental prosthesis. There were 42 eligible reports. The authors developed a codebook to qualitatively analyze the root cause analyses according to the event types that emerged thematically.

Results

The most frequently occurring safety incident was wrong-site surgery (40.48%), followed by ingestion (19.05%) and the use of inadequately sterilized equipment (7.14%). Lack of policy was the most common cause of adverse events and the action most recommended was to develop or review a protocol.

Conclusions

An analysis in the VHA revealed the most frequent adverse event was wrong-site surgery. Additional studies in the general public are recommended to compare findings.

Practical Implications

The authors provide insight into the nature of adverse events, although there are limitations to this study because reporting remains voluntary. The findings should encourage discourse on how dental offices can seek to improve patient safety and safety culture.