NHS England has removed wrong site intraoral blocks from its list of Never Events, or the kinds of mistakes that should never happen in medical treatment. A joint NHS England-NHS Improvement working group recommended the change last year.
While the definition of the “wrong site surgery” category of Never Events includes wrong site block for pain relief, local anesthetic blocks for dental blocks for dental procedures has been added to the list of exclusions.
However, the administration of local anesthesia in the wrong site by dental professionals still will be classified as a Patient Safety Incident.
NHS Improvement defines Never Events as incidents with “the potential to cause serious patient harm or death” that are “wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers.”
“I’m delighted that wrong site block has been reclassified as a Patient Safety Incident. It really never should have been classified as a Never Event in the first place, as systemic barriers are not in place to make it whole preventable, and it is questionable whether it causes serious patient harm,” said Mick Horton, former dean of the FGDP(UK), who represented the FGDP(UK) on the working group that recommended the exclusion.
The removal leaves wrong site tooth extraction as the only dental Never Event. Practice teams can minimize the risk of wrong site tooth extractions by consulting the related NHS Local Safety Standard for Invasive Procedures toolkit, the FGDP(UK) says, which was developed with input from the FGDP(UK).
The FGDP(UK) also is seeking the introduction of an independent, trustworthy, and anonymous system for reporting all Significant Events in dental practice, including Never Events, to enable the profession to adapt its practice in response to the research and risk analysis such a resource would facilitate.