Kristy Pilatzke, Risk and Compliance Officer, dentalcorp
- A soiled scaler caught between the top and bottom of the cassette, the sharp side poking out.
- Different post-treatment instructions provided by different doctors for the same procedure.
- The electrical cord from a dental chair laying across a high traffic area.
- A dangerously high blood pressure reading prior to commencing a lengthy appointment.
- A dental assistant bumping into a doctor’s delivery system just missing the handpiece with a soiled bur still in place.
- An electrical outlet that has suddenly become discoloured.
- A soiled scalpel blade left on the handle amongst other instruments headed for reprocessing.
- Medical history updates captured inconsistently in different areas of the electronic PMS.
In healthcare, instances of close calls are commonly referred to as “near misses[1] ” and are often overlooked, disregarded, or easily forgotten. In 2022, dentalcorp launched its first Good Catch campaign aimed at celebrating the identification and reporting of “near misses” while simultaneously promoting a culture of safety across all our Practices. Near misses include potentially dangerous events that are caught or corrected before any harm occurs. To encourage participation, dentalcorp recognized Practices that consistently reported good catches, as well as the Practice deemed to best reduce risk, increase safety, and reflect a strong practice safety culture.
With our studies indicating that thousands of similar incidents occur daily within dental offices across Canada, the Good Catch campaign was designed to raise awareness of such risks and encourage a shift in the mindset of dental clinic workers regarding safety. Rather than defining safety post-incident as “the absence of an injury”, safety becomes a conscious decision to maintain and preserve healthy, safe working conditions.
One of our Practice Managers indicated “It's amazing how many “near misses” there are when you start to pay attention!”. It's true. According to safety experts, “near misses” occur 3 to 300 times more frequently than adverse events[2] but only a fraction of these are identified and recorded in an organization’s incident reporting system. While it is easy to understand why this may be, failing to pause and address unsafe conditions leaves the risk in place. Often, the only difference between a “near miss” and serious harm is luck. The best way to prevent future incidents, therefore, is to learn from and address the conditions that had the potential to cause harm today but didn’t.
Historically, “near misses” represented 5% of the events captured in dc safety, dentalcorp’s safety incident reporting system. However, with the Good Catch campaign, we noticed a 40% increase in reported “near miss” incidents, an important step in improving safety and patient care resulting in less adverse events.[3]
The following approaches were used to garner engagement and participation from our clinical teams:
- Set a positive tone by making the program voluntary and gamifying the reporting process by offering rewards for not only the highest volume but best “near misses” reported.
- Minimize time commitment ensuring unfettered access to quick electronic reporting.
- Providing timely feedback by ensuring a response was provided to each report, in most cases the same day, to thank team members for their commitment to safety, connecting the report back to historical safety incidents reported, and offering support with investigations when needed.
- Eliciting continuous improvement by challenging practices to identify and implement ways to prevent similar issues from recurring.
- Celebrating wins by highlighting extraordinary examples of “near misses” through organization-wide training and communications
Throughout the campaign, practice team members reflected on not only what went wrong but also what went right with the “near misses” identified. In fact, one Practice Manager indicated “This has been a GREAT initiative. It's definitely helped my team think more about safety and what we can do better.”
Each of these reports represents an opportunity to learn, without harm to patients and/or team members. Sometimes this learning is as simple as a realization and connection back to the purpose; the ‘why’. For example, as a standard practice, a clinic uses locked puncture-proof trays to transport unprocessed instruments from operatories to the sterilization area. One day in the busy practice, two Dental Hygienists crash into each other, and the trays of soiled instruments they are carrying fall to the floor. By design, locked tray covers prevent a biohazard, risky clean-up effort, or sharps injury. Through identifying and reporting this issue, the team is reminded why processes and tools have been adopted. When such incidents are not reported and discussed, it is possible some people question why certain protocols are in place. The term for this widespread and well-understood phenomenon is the “normalization of deviance.” By bringing attention to near misses, teams prevent such forces from taking hold.
Reporting near misses also sends the message that safety is everyone’s responsibility and reinforces the importance of sound communication amongst teams. For example, a Practice Manager (PM) and a Dental Assistant (DA) were working together to wrap unprocessed cassettes for sterilization. The PM identified a scaler poking out of the end and pointed it out to the DA who readjusted the instrument.
Because the PM was on the lookout, she spoke up, and because she spoke up, a potential injury was avoided without adding time to anyone’s job. Furthermore, nothing creates a positive workplace environment like the comfort of knowing that all of your teammates have your back. In a second example, two team members were processing instruments. As one of the team members was stamping the packages, the other noticed and advised that the incorrect date was being used. By speaking up, one colleague prevented the stress and confusion that would have resulted had the packages been processed with an incorrect date. In a final example, a team member noticed a cupboard was left open above another team member who was working below. By closing the cupboard door, the individual was helping their fellow team member avoid a possible injury like a concussion.
In busy dental clinics where team members are often interrupted or distracted, there is an increased risk of errors or safety incidents. With the Good Catch campaign, these clinics were able to pause, reflect, and embrace the learning opportunity in front of them. Through this initiative, Practices were empowered to leverage key skills such as self-reflection, situational awareness, communication, and teamwork to make their practice safer, not just for themselves, but for everyone who walks through their doors.
[1] Canadian Patient Safety Institute | Home / Tools & Resources / Patient Safety and Incident Management Toolkit / Glossary: https://www.patientsafetyinstitute.ca/en/toolsResources/PatientSafetyIncidentManagementToolkit/pages/glossary.aspx, last accessed on March 7, 2023.
[2] Barnard D, Dumkee M, Bains B, Gallivan B. Implementing a good catch program in an integrated health system. Healthcare Quarterly. 2006 Oct;9:22-7
[3] Pennsylvania Patient Safety Advisory. Promote a Culture of Safety with Good Catch Reports. 2017. Pennsylvania Patient Safety Advisory, 14(3). Accessed June 27, 2022 from http://patientsafety.pa.gov/ADVISORIES/Pages/201709_goodcatch.aspx