Safety Protocols Using Implant Checklists

In 1999, the U.S. Institute of Medicine published a report, “To Err Is Human,” which revealed that more Americans die annually due to medical errors than traffic accidents.¹ This report, among others, led to the new discipline of patient safety, and helped galvanize efforts to promote a culture of safe practice among the health care professions. While many of these patient safety-related efforts have been focused on medicine, dentistry, by comparison, has been a relative latecomer to the concept of a safety-based practice.² Using implant checklists as an example, this article will examine how patient safety can be addressed in dental settings to help raise the level of care provided.

Yamalik and Perea Pérez² discussed several “peculiarities of patient safety in dentistry” that serve as barriers for development of a safety culture. For one, iatrogenic injury to patients is typically milder in dentistry compared to medicine because dental procedures tend to be less invasive. Deaths related to dental procedures are relatively rare. In addition, dental care is largely unstructured and often provided by dentists who practice in relative isolation. This structure limits the dissemination of knowledge regarding adverse events, as well as their analysis. Lastly, dentists have no incentive to report adverse events, considering that most dental procedures take place in private practice settings. This is particularly true when the event may reflect a professional error and/or have negative financial consequences.

There are few statistics available on patient safety incidents (PSI) — such as near misses or adverse events — occurring in dental practice. A large portion of the available information on PSI stems from case studies, which range from less severe events, such as local allergy to dental materials, to life-threatening events, such as airway obstruction or even death.^3,4

In terms of dental implants, recent advances in site development and placement techniques have made the practice of implant dentistry more effective, but also more dangerous.^5,6 The American Academy of Implant Dentistry estimates that approximately 3 million Americans have implants, and this number is growing by 500,000 annually.⁷ Despite the rapid expansion, several safety and quality-of-care issues need to be addressed to reduce the associated risks.⁸

Experience in placing implants varies widely among clinicians.^9–14 In terms of quality of care, implant survival rates are relatively well documented.^15,16 For example, a meta-analysis by Pjetturson et al¹⁵ revealed that although dental implants placed by experienced surgeons had a 95% survival rate within five years of placement, 39% of these surviving implants were associated with at least one complication. Common problems, such as those involving prosthetics, may become more serious when clinician experience is limited.¹⁶ For example, implants placed by inexperienced surgeons were shown to be twice as likely to fail as those placed by experienced surgeons.¹⁷ When clinicians make iatrogenic errors — especially those leading to patient morbidity and mortality — they face loss of licensure and other legal ramifications.¹⁸ In 2012, 11% of medical malpractice payments were against dentists.^19,20

Understanding how errors occur is paramount to patient safety, and several models have been proposed to conceptualize this. Reason’s “Swiss cheese” model focuses on built-in preventive mechanisms that may act as barriers to errors.²¹ In actual practice, each barrier is more like a slice of Swiss cheese, meaning that while there may be holes, collectively, they help prevent errors. Nevertheless, when several minor errors occur in concert, they can trigger an adverse event.

Another way to think about errors is to consider the buildup of risks that eventually leads to a PSI. Sometimes failures in organizational systems can result in human errors — such as structure that is too complex, inappropriate automation, reliance on memory for optimizing information systems, lack of physical/engineering constraints, and the effects of change on systems.²²

PUT A PLAN IN PLACE

Developing a patient-centered safety climate is critical to preventing PSI.²³ The goal is not to identify individuals to blame, but to find system mistakes and prevent errors from occurring.² Yamalik and Perea Pérez² proposed the adoption of steps to encourage an effective safety culture. Table 1 provides a list of these steps.²

The World Health Organization (WHO) published a surgical safety checklist (available HERE). This checklist was developed to reduce human error during surgical procedures and is modeled after the airline industry’s in-flight safety checklists.^24–26 It includes three phases: sign in before induction of anesthesia; time out before skin incision; and sign out before the patient leaves the operating room. The operating team checks off each item before proceeding to the next phase.

With complex clinical decision-making systems, health care practitioners face two main challenges: fallibility of memory and attention, and the inadvertent skipping of clinical steps.^24,27 Despite receiving extensive training, some clinicians assume that certain steps may not always be essential.²⁴ This is why making key procedures explicitly routine is critical. In addition, checklists provide clinicians with clear reminders of the minimum steps necessary for the procedure, with the aim of avoiding or catching any significant procedural errors.²⁴

Checklists provide clinicians with clear reminders of the minimum steps necessary for the procedure, with the aim of avoiding … procedural errors

Several studies have shown the effectiveness of the WHO checklist. Many well-controlled studies have demonstrated the beneficial effects of implementing checklists in reducing patient morbidity and mortality in various hospital settings.^28–30 In contrast, Urbach et al³¹ reported that a law mandating surgical checklist use in Ontario hospitals resulted only in a modest, statistically insignificant reduction in mortality. In light of this report, Haugen et al³² conducted a randomized clinical trial of the surgery checklist, which confirmed that its use resulted in substantial improvement in outcomes. More importantly, the authors detailed several factors that may have improved the list’s efficacy. First, customizing the checklist to fit the practice setting was key to its success. Also, testing the checklist on a small scale and then making further modifications proved to be helpful. Practitioners should be free to make observations and suggestions in order to create opportunities for additional education and reinforcement.^32,33

DENTAL IMPLANT CHECKLIST

As dental implant placement is more akin to medical surgical procedures than routine dental procedures, Christman et al³⁴ created a preliminary surgical safety checklist for dental implant placement.^34–36 The expectation was that dental practitioners could then customize the framework based on individual practice needs. In the following sections, the process by which the checklist was created will be briefly discussed, and key findings will be summarized.

The process involved obtaining consensus from a panel of experts to create a checklist that would provide a preliminary framework for minimizing risks. The authors administered the survey to 24 board-certified periodontists, who came to a consensus on the appropriate clinical steps for the successful restoration of edentulous areas with dental implants. The panel ultimately determined that 20 items were essential to the checklist, and arranged them in three phases: treatment planning, intraoperative and postoperative (Table 2). The broad consensus among the panelists was:

• In preparing treatment plans for patients, clinicians should verify periodontal stability, conduct a proper diagnostic workup, and engage in effective communication with restorative partners.
• Important steps include thoroughly reviewing the patient’s medical and dental history before placing implants, and using safety checklists.
• Postoperative care should include appropriate communication with patients and restorative partners.

In terms of treatment planning, the panelists note that verification of patients’ periodontal stability is critical, and they emphasize the need for thorough clinical and radiographic evaluation to establish this stability. The experts also encourage the use of appropriate diagnostic aids — such as radiographs and cone beam computed tomography — to help identify key anatomical structures. The consequences of failing to identify and protect such structures are documented extensively in the literature. In a meta-analysis of complications related to implant placement, the most common surgical problems were associated with hemorrhage.¹² In addition, the incidence of persistent or long-term altered sensation of the mental nerve after implant surgery varies from 1% to 43%.^37,38

The panel points out that reviewing the patient’s medical and dental history is critical to preventing medical emergencies, and it emphasizes the need to identify relative or absolute contraindications to implant placement. The panelists also suggest that formal treatment plans should be determined for complex cases, and recommend obtaining signed consent from patients for any proposed treatment in order to protect clinicians in case of possible legal action.

Following a prescribed, standardized safety checklist may prove useful in reducing errors associated with implant placement

In terms of intraoperative steps, all panelists concur that a review of current medications and an exploration of any changes to the pa­tient’s dental or medical history must be done on the day of surgery. They assert that protecting the airway is critical, but offer the caveat that achieving this goal may be difficult due to space restrictions. The dental literature contains re­ports of sporadic occurrences of surgical instrument aspiration and associated life-threatening complications.^14,39 Consequently, the expert panel advocates the use of safety measures, such as placing gauze at the back of the throat, and emphasizes the importance of monitoring vital signs during administration of conscious sedation.

Consistent with Greenstein and colleagues,⁴⁰ several experts suggest that sound clinical judgment and evaluation of bone quality are the most important factors in determining drill speeds and torque values, but the panel did not reach consensus on these points. Reported causes of initial integration failures include high heat levels due to drilling, and excessive pressure at the implant-bone interface (i.e., greater torque values) at the time of implant insertion, which may result in retrograde peri-implantitis lesions.⁴¹

The panelists agree on the essential need for intraoperative radiographs in areas where space is limited due to anatomical constraints. They also suggest that verifying implant angulation and positioning with the help of a qualified assistant, and obtaining final radiographs after implant placement are wise clinical practices.

Tarnow et al⁴² reported that improper mesio-distal angulation and positioning of implants can lead to lateral bone loss, as well as unacceptable esthetic results. Invasion of the periodontal ligament space and devitalization of adjacent teeth due to improper angulation and positioning are additional concerns related to improper implant placement.⁴³

In terms of postoperative steps, the panelists advocate prescribing chlor­hexidine mouth­rinses, providing patients with written postoperative instructions, communicating after surgery with res­torative partners, making follow-up calls to patients, and scheduling follow-up appointments as essential clinical practices.^8,40 Reported postoperative infec­tion rates are low, but such conditions can lead to serious adverse events beyond the oral cavity.⁸ Consequently, following a prescribed, standardized safety checklist may prove useful in reducing errors associated with implant placement.

While the medical field is making tremendous strides in promoting a safety culture, dentistry still needs to ramp up its efforts

CONCLUSION

While the medical field is making tremendous strides in promoting a safety culture, dentistry still needs to ramp up its efforts. Some of the factors that are instrumental to initiating a safety culture in the dental setting include:

1. Creating strategies that promote group orientation and reduce influence of hierarchy.
2. Providing and promoting multidisciplinary training as part of dental education and continuing education programs.
3. Developing quality improvement tools to gather databases of PSIs, as well as further development, improvement and implementation of checklists.
4. Customizing checklists and encouraging ownership by all members of the dental team.

Christman et al³⁴ made the first attempt to design a standardized safety checklist for dental implant surgeries. Further research is needed to evaluate improvements in outcomes. Unique implementation challenges related to dentistry need to be identified. While adverse events may occur less frequently in dentistry than medicine, they can still exert serious consequences on patient health and quality of life. A culture of safety and the use of implant checklists will not only benefit patients, but practitioners, as well.

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