Patient safety in dental care: an integrative review Segurança do paciente no cuidado odontológico: revisão integrativa Seguridad del paciente en el cuidado odontológico: revisión integradora

Adverse events pose a serious problem for quality of healthcare. Dental practice is eminently invasive and involves close and routine contact with secretions; as such, it is potentially prone to the occurrence of adverse events. Various patient safety studies have been developed in the last two decades, but mostly in the hospital setting due to the organizational complexity, severity of the cases, and diversity and specificity of the procedures. The objective was to identify and explore studies on patient safety in Dentistry. An integrative literature review was performed in MEDLINE via PubMed, Scopus via Portal Capes, and the Regional Portal of the Virtual Health Library, using the terms patient safety and dentistry in English, Spanish, and Portuguese, starting in 2000. The research cycle in patient safety was used, as proposed by the World Health Organization to classify studies. We analyzed 91 articles. The most common adverse events were allergies, infections, diagnostic delay or failure, and technical error. Measures to mitigate the problem highlight the need to improve communications, encourage reporting, and search for tools to assist the management of care. The authors found a lack of studies on implementation and assessment of the impact of proposals for improvement. Dentistry has made progress in patient safety but still needs to transpose the results into practice, where efforts are crucial to prevent adverse events. Patient Safety; Dentistry; Quality of Health Care; Adverse Event REVISÃO REVIEW This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited. Corrêa CDTSO et al. 2 Cad. Saúde Pública 2020; 36(10):e00197819 Introduction The World Health Organization (WHO) defines patient safety as “the reduction of risk of unnecessary harms related to healthcare to an acceptable minimum” 1 (p. 21). The focus is on the prevention of adverse events (AE), defined as harms to the patient resulting from the care rather than the underlying disease 1. The theme of patient safety and quality of care has been with us for some time 2. However, it was not until the publications To Err is Human: Building a Safer Health System 3 and Crossing the Quality Chasm: A New Health System for the 21st Century 4 by the U.S. Institute of Medicine that the problem’s magnitude and its clinical, economic, and social dimensions were exposed more clearly, underscoring the gap between the promised quality and the quality actually delivered. Since then, under the leadership of international organizations, especially the WHO, patient safety has gained its own body of scientific knowledge 5. Studies have grown and are proving essential for: (i) producing knowledge in the area; (ii) disseminating information; (iii) supporting decisions; (iv) promoting evidence-based practices; and (v) monitoring and assessing the impact of measures aimed at increasing patient safety and improving the quality of patient care 6. Most of the studies have been conducted in the hospital setting, probably due to its organizational complexity, severity of the cases, diversity, and specificity of procedures 7. Although dentists’ work is mostly in the outpatient setting, the provision of dental care is prone to the occurrence of AE. Dental practice is eminently invasive, involves close and routine contact with secretions such as saliva and blood 8; depends on the professional’s skill, and entails constant exposure to possible medical emergencies 9,10. Meanwhile, major technological progress in recent decades led to greater ease and precision in diagnoses and treatments 11, while adding greater complexity to the care and thus increasing the risk of dental AE 12. Given this scenario, the article aimed to identify and explore studies focused on patient safety in Dentistry. It is essential to explore the contents of these publications to highlight possible contributions to practice and identify potential points of departure for continuity, indispensable for understanding the problem and seeking improvements in quality of care and patient safety in this context.


Introduction
The World Health Organization (WHO) defines patient safety as "the reduction of risk of unnecessary harms related to healthcare to an acceptable minimum" 1 (p. 21). The focus is on the prevention of adverse events (AE), defined as harms to the patient resulting from the care rather than the underlying disease 1 .
The theme of patient safety and quality of care has been with us for some time 2 . However, it was not until the publications To Err is Human: Building a Safer Health System 3 and Crossing the Quality Chasm: A New Health System for the 21 st Century 4 by the U.S. Institute of Medicine that the problem's magnitude and its clinical, economic, and social dimensions were exposed more clearly, underscoring the gap between the promised quality and the quality actually delivered.
Since then, under the leadership of international organizations, especially the WHO, patient safety has gained its own body of scientific knowledge 5 . Studies have grown and are proving essential for: (i) producing knowledge in the area; (ii) disseminating information; (iii) supporting decisions; (iv) promoting evidence-based practices; and (v) monitoring and assessing the impact of measures aimed at increasing patient safety and improving the quality of patient care 6 .
Most of the studies have been conducted in the hospital setting, probably due to its organizational complexity, severity of the cases, diversity, and specificity of procedures 7 . Although dentists' work is mostly in the outpatient setting, the provision of dental care is prone to the occurrence of AE. Dental practice is eminently invasive, involves close and routine contact with secretions such as saliva and blood 8 ; depends on the professional's skill, and entails constant exposure to possible medical emergencies 9,10 .
Meanwhile, major technological progress in recent decades led to greater ease and precision in diagnoses and treatments 11 , while adding greater complexity to the care and thus increasing the risk of dental AE 12 .
Given this scenario, the article aimed to identify and explore studies focused on patient safety in Dentistry. It is essential to explore the contents of these publications to highlight possible contributions to practice and identify potential points of departure for continuity, indispensable for understanding the problem and seeking improvements in quality of care and patient safety in this context.

Method
This was an integrative literature review oriented by the following question: "What research developments have occurred in the field of patient safety in Dentistry, and what contributions have the studies made to the safety of care?". To answer this question, we conducted searches in the databases MEDLINE via PubMed, VHL Regional, and Scopus via Portal Capes, since these contain most of the publications in the health field. We used the terms from the MeSH terms (Medical Subject Headings; https://www.ncbi.nlm.nih.gov/mesh/) in English: patient safety and dentistry in the title and/or abstract (Box 1).
The inclusion criteria were: scientific articles in English, Spanish, or Portuguese, by authors' convenience, and representing the great majority of publications in this area; that prioritized patient safety in Dentistry, that included quantitative, qualitative, evaluative, intervention, reflection, document analysis, and literature review methodologies; published since January 1, 2000 -the year of publication of the report To Err is Human: Building a Safer Health System -until June 30, 2019.
Exclusion criteria were articles that did not address patient safety as the central approach, such as: those focusing mainly on legal aspects, workers' health, and biosafety; articles involving other health professions; editorials, letters, recommendations by agencies/institutions, opinions/commentary, and interviews; duplicate articles; those without abstracts; and non-accessible publications. The titles and abstracts were read by two independent reviewers, and doubts were resolved by consensus between the two.
The included studies were categorized by year, country of publication, method, and main objective. The latter categorization, conducted by the authors, was based on an approach to the components in the research cycle proposed by the WHO 6 (Box 2); descriptive studies that analyzed and discussed patient safety concepts and their application to Dentistry but which did not allow fitting them into the research cycle's components were classified as "others". Cad VHL Regional (tw:("patient safety")) AND (tw:(dentistry)) AND (instance: "regional") AND db:("LILACS" OR "BBO" OR "IBECS"") AND la:("es" OR "pt" OR "en") AND type:("article") Scopus TITLE-ABS-KEY ("patient safety" AND dentistry) AND DOCTYPE (ar OR re) AND PUBYEAR > 1999 AND PUBYEAR < 2020 AND (LIMIT-TO (LANGUAGE, "English") OR LIMIT-TO (LANGUAGE, "Portuguese") OR LIMIT-TO (LANGUAGE, "Spanish") Source: prepared by the authors.

Box 2
Patient safety research cycle proposed by the World Health Organization (WHO).

Results
The search in the three databases identified 315 articles: 95 captured by MEDLINE, 21 via VHL Regional, and 199 through Scopus. After excluding 99 articles, 86 duplicates, 7 without an available abstract, and 6 unavailable, 216 articles were selected for reading the title and abstract. Based on the references found, 9 more articles were captured and added to the sample ( Figure 1). The final sample consisted of 91 articles. Countries with the most publications were United States (39.3%; n = 33) and England (31%; n = 28); Brazil, Canada, China, Chile, Scotland, Netherlands, Mexico, Pakistan, Sweden, and Switzerland presented only 1 publication each during the period (Table 1).
Based on the included studies' objectives, categorized by the components of the research cycle proposed by the WHO 6 , we found that some studies addressed more than one component. Most were focused on the initial phases: measuring the harm (28.6%; n = 26); understanding the causes

Focus on patient safety in Dentistry
Publications on patient safety in Dentistry have grown worldwide, although with just minor increases; England and the United States accounted for most of the included studies. A strong primary healthcare (PHC) system, as in England, and pioneering work in institutions dedicated to healthcare quality improvement, as in the United States, may help explain these findings.
The area's specificities may point to reasons for the low number of studies: (i) procedures that are generally less invasive than those of medical surgery and are thus less prone to serious harms; (ii) dental complications are often treated in hospital emergency departments, and the initial attending dentist may thus not learn of the incident; (iii) a large share of the care takes places in the private sector and/or in individual dentists' offices, and fear of losing patients may limit reporting of the harm; and (iv) less familiarity with the issue in private practices than in the hospital setting, which is historically more amenable to campaigns, courses, and greater control of AE 9,13 .
However, while some characteristics may explain the lack of contact with patient safety issues, other characteristics raise challenges for professional dental practice that should encourage more studies. We highlight the predominance of surgical procedures and their complications, such as bleed- ing and infections, constant exposure to ionizing radiation, and the need to be alert to the patient's health history 10 .
We observed a similar trend in studies in patient safety in Dentistry to those of patient safety in general 14,15 in relation to the sources and techniques adopted. The initial studies, which were exploratory, sought to draw a parallel between dentistry and patient safety 9,10,16,17,18,19,20 . These then gave way to more specific approaches 21,22 , suggesting greater participation by Dentistry in the multidisciplinary approach that the patient safety theme requires.

The problem's size and understanding its causes
While the first studies in patient safety aimed to measure the incidence or prevalence of AE to know the problem's magnitude 6 , the initial studies in Dentistry, besides measuring their frequency, aimed to understand their causes, sparking reflection on the inherent challenges in the specificities of dental practice. From the perspective of measuring the incidence/prevalence of harms, the studies 12,21,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43 produced findings that ranges from the complications of local anesthesia/sedation; lesions to the tongue and lips; and loss of teeth from switched tooth extractions, ocular lesions and even death. Incidents involved allergies, infections, diagnostic delay or failure, and failure in the procedure, among others. However, as addressed appropriately by Ensaldo-Carrasco et al. 35 , the evidence is still considered insufficient to provide reliable estimates on the incidence and frequency of these events.
In the effort to characterize "never events" in dentistry, defined as incidents that resulted in death or significant disability for the patient and that should never occur 44 , three studies used a qualitative methodology and produced distinct classifications 44,45,46 . Renton & Sabbah 44 used a list of never events from the English National Health Service (NHS) updated in 2015/2016. Black & Bowie 45 refined 507 suggestions from 250 dentists using the modified Delphi method. Ensaldo-Carrasco et al. 46 also used the modified Delphi method, but drew on the literature to create an initial list of never events that was then refined by 41 specialists from various countries.
To study the avoidability of AE, Pérez Gómez et al. 41 analyzed 595 patient charts and found 36 AE. Of these, 21 (58%) were considered avoidable. Mettes et al. 24 identified a total of 46 dental AE, 39% of which were considered avoidable. The authors inferred that although the relatively low percentage of avoidable AE suggested safety in dental practice, the records' low quality plus the subjectivity of the avoidability concept may imply the measure's underestimation. The situation calls for a critical analysis, especially when comparing the above-mentioned studies with two others: Huertas et al. 39 in which 43 of the 227 complaints analyzed were classified as AE, 42 (98%) avoidable, and Pesántez Alvarado et al. 40 , analyzing 1,062 clinical histories of patients that underwent surgical procedures and identifying 11 AE, 9 of which (82%) were classified as avoidable.
The contributing factors to unsafe care featured diagnostic and/or planning errors, ineffective communication, failure in the performance of procedures, low adherence to protocol, and insufficient history-taking 25,33,39,43,47,48 . These factors were described in turn as either latent or active. Obadan et al. 31 analyzed hypothetically the accidental ingestion of foreign bodies and pointed to low clinical capacity, inadequate training, and deficient equipment maintenance as possible latent failures and inadequate protection of the patient's airways as an active failure.
AE resulting from medication include prescription, dispensing, and administration and are widely described in the scientific literature. In the context of PHC, drug prescription was reported as one of the principal causes of AE 49 , corroborating the object of one of the first studies included: drug prescription in Dentistry 50 .
Studies have demonstrated the need to focus attention on the use of medicines and other substances. The sugar in many pharmaceuticals can act as a cofactor for caries, particularly in patients with difficulty swallowing 51 . Weight-loss drugs 52 , dietary supplements 53 , and vitamin supplements 54 were also emphasized, suggesting that dentists should take these conditions into account in order to elaborate a safe, patient-centered treatment proposal.
Another concern is the association between AE and the technologies employed in dental care 55,56 . Along this line, Hebballi et al. 32 analyzed the reports of incidents with health devices notified to the U.S. Food and Drug Administration (FDA) in 2011. The results showed that out of a total of 1,978,056 reports, 28,046 (1.4%) were associated with dental devices. Some of the reports (2,942) were excluded because they did not furnish adequate information. Of the reports analyzed, 17,261 were related to injuries, 7,777 to poor functioning of the device, and 66 to deaths. Of these, 52 were clearly associated with the dental device.
Importantly, contributing factors are not associated only with the patient, but also with the healthcare providers and the work environment. Factors associated with patient characteristics include motor and/or intellectual disabilities and characteristics of children and the elderly. Factors associated with work conditions and the healthcare professional include agitated settings that favor distractions, high patient turnover, lack of skills from training, and deficient visibility and communication 57 .
Training is essential for dealing with the problems that professionals may face during their careers 58,59,60 , and it is important to incorporate the theme of patient safety starting in the early years of undergraduate school 61 . One study 39 of Dentistry students identified predisposing human factors related to AE such as operator fatigue, unawareness of risks, and failures of referrals. Corroborating these findings, Osegueda-Espinosa et al. 38 called attention to the need for more active supervision in academic settings.
The studies confirm the importance of dentists' training to prepare them to identify urgencies and situations that escape their control in order to proceed to adequate referrals, as emphasized by Al Blaihed et al. 62 , who described difficulties by professors in reporting incidents committed by students. They found that although there were verbal reports, the incidents were not recorded in writing, suggesting a weak local safety culture.
Patient safety culture means the beliefs, values, and standards shared by professionals and that also influence their behaviors and actions 63 . In the course of this review, studies alluded to the theme 13,64,65 or used it as their central focus 47,61,66,67,68,69,70,71,72,73 . Positive points were found, such has a high overall perception of patient safety; patient-centered care; the pursuit of effective and equitable care; and the value assigned to teamwork. The weaknesses described were low reporting of incidents and shortage of training, insufficient patient follow-up, and lack of the leadership's support for patient safety.
It is essential to also focus on organizational factors such as failures in the physical environment, scheduling and managing patients, lines of responsibility, and influence of policies 35 . A study of dental hygiene technicians showed that their perception of patient safety is inversely proportional to the number of hours worked and the number of patients treated 73 .
Evidence shows that professionals involved in AE can suffer emotions that affect their performance and their health, potentially leading to substance use and depression 74 . Support by the organization for the professional involved in AE, also called the "second victim", is one of the key issues for safety of care. Non-punitive support in cases of safety incidents and AE, as well as simplification of reporting systems can help enhance this approach 70,75 . To allow an in-depth understanding of the AE problem requires combining the professionals' technical knowledge with their cognitive and behavior aspects 76 .
Finally, the implementation of policies and periodic monitoring of compliance with clinical practice guidelines and patient safety 77 are necessary. The unavailability of national laws and/or regulations on patient safety in dentistry suggests low social awareness of the problem 67 .

The solutions identified and their contribution to improvement in clinical safety
Studies on safety in surgical procedures were highlighted, possibly due to their more invasive nature. One study 78 discussed the process of marking the surgical site as an opportunity for communication between patients and professionals, allowing to reduce the odds of errors such as switched tooth extractions, which is a major concern 44,79 . Improvement in communication led to the development of a chart for display in the hospital setting, in which healthcare professionals recorded the unsafe events that occurred during routine dental care, and which contributed to periodic discussions of quality improvement by the team 64 .
In order to improve safety in anesthesia, adequate monitoring and a highly trained team were identified as key factors 80,81 . In addition, a systematic review suggested the routine addition of capnography to standard monitoring of adults during moderate sedation 22 .
Checklists were considered effective in the improvement of work processes, optimization of communication, and the reduction of stress levels in surgeries 78,81,82,83,84,85,86 . They also proved useful in the support of cancer diagnosis 87 and strengthening the safety culture 88 .
For endodontic treatment, in addition to a checklist 89 , a protocol was proposed to decrease the occurrence of incidents with ultrasound energy 55 and the use of rubber dams 90,91 . The latter is a device that isolates the dental element for the endodontic procedure and avoids incidents such as aspiration and/or swallowing of artifacts.
As solutions to prevent drug-related AE, Skaar & O'Connor 92 emphasized the need to increase dentists' knowledge of the prescribed drugs and their interactions. Donaldson & Goodchild 93 emphasized the importance of orientation for these professionals on the use of pharmacological antagonists to help mitigate drug-induced medical emergencies.
Meanwhile, Noguerado et al. 94 proposed a guide for drug prescription for pregnant and breastfeeding women, and Hussein et al. 95 suggested a set of indicators to improve prescription quality.
Cad. Saúde Pública 2020; 36(10):e00197819 Importantly, many medication errors occur due to failures that could easily be avoided, including low adherence to protocols and filling out illegible prescriptions 96 . Clinical activities in a university should represent the gold standard for professional performance 97 , and the implementation of educational programs could benefit the necessary development of dentists' prescribing skills 98,99 .
Quality improvement methodologies tend to favor patient safety 29,97 . For example, the clinical audit is a useful tool, especially if: (i) it is structured formally and continuously with a regular schedule of meetings and events with permission for direct vertical and horizontal communication; (ii) training includes a significant number of staffers; (iii) it is aligned with local priorities; (iv) there is follow-up of all its phases (recording, data collection, data analysis, and report); and (v) there is timely monitoring of each recommendation in the action plan and its conclusion is reached before the next audit cycle is executed 100 .
Another available tool is risk analysis. For patients with motor and/or cognitive needs that require specific care, Perea-Pérez et al. 57 proposed a specific risk analysis, which considers the risks related to patients and those associated with the professionals and the healthcare setting.
Reports of incidents constitute an excellent source of organizational learning and serve as substrate for the elaboration of strategies and interventions to improve patient safety 28 . Authors that used mixed databases, that is, that involved reports on health areas in general suggested that a specific reporting system for dental patients could facilitate both reporting and subsequent analysis of these events 12 .
However, it is necessary to develop institutional policies to reduce barriers that hinder reporting by professionals 12,66,75 and to involve patients and their families, encouraging them to report harms 101 . Population awareness-raising of the problem is also important in the policies' wider sphere 102 .
Many AE could be avoided by maintaining precise patient records 103 . Informed consent attached to the patient file has proven valuable by placing the patient at the center of the treatment decisions 104 . Adding photos and X-rays to the patient chart, recording situations pertaining to the incidents, as well as lab test results, can by highly useful in the analysis and assessment of AE 41 .
Still, patient safety in Dentistry is multifactorial and complex 9 . The proposed solutions assume strong organizational action and teamwork. Such structural conditions are not always favorable, due to the inherent characteristics of dental care provision itself or other organizational factors.
Research efforts are thus explicitly needed in patient safety in Dentistry, aimed at assisting the systematization and organization of the provision of care and helping reduce AE in the field.

Study limitations
The study presents some limitations. The integrative review is an important tool that allows analyzing the literature widely and systematically. However, the search terms in the databases only included English, Portuguese, and Spanish, which may have limited the number of articles retrieved. Another limitation related to the search terms is the fact that they did not include the MeSH term adverse events, widely used to index publications on patient safety. To mitigate this issue, the authors expanded the search beyond the MeSH terms used, including the term patient safety in titles and abstracts, which allowed retrieving studies published since 2005. The use of only three reference databases may also have introduced a bias, although the authors felt that the three databases cover the major research output in the health field. In the literature search, 13 articles were excluded. Seven of these did not present an available abstract and 6 were inaccessible. Thus, the review did not include potential findings from the 13 studies. In the attempt to minimize these biases, 9 more articles were included, based on analysis of the references from the retrieved articles.

Conclusion
The publications showed that Dentistry is evolving towards better knowledge of patient safety issues, especially in developed countries. The possibility of collecting studies with diverse methodologies and objectives contributed to describing their actual role in the theme and allowed identifying a range of proposals for improving patient care safety.
Cad. Saúde Pública 2020; 36(10):e00197819 Healthcare's complexity includes factors inherent to the setting and to human action, which in Dentistry amplifies the odds of AE through single and fragmented work. Shaping a favorable environment for patient safety in dentistry requires involvement by universities, industry, and the services' administration, together with the healthcare professionals directly providing the care, the patients, and their families. In this sense, qualitative studies proved quite useful, although few in number in this review.
As in other professions that produce the direct fruits of human labor, the results of the care depend largely on the attending professional. Thus, training, ergonomics, sufficient time to conduct the care, and appropriate operational inputs were identified as crucial for the real work to approach the ideal and reduce the risk of harms to dental patients.
The trend in research according to the components of the cycle proposed by the WHO showed that studies dedicated to the first phase, namely measuring the harm, were not the majority. The main AE in Dentistry were: hard and soft tissue lesions to the oral cavity, with special attention to switched tooth extractions; allergies, anesthetic complications, and infections, circumstances which if aggravated can even lead to death. Many studies addressed the importance of understanding the causes of AE and identifying solutions to avoid them, in an effort to mitigate the problem.
Contributing factors included failures in planning and management of care, ineffective communication, inadequate use of technologies, deficiencies in training, and a weak safety culture. The study instruments' proposals and the methods presented to decrease the problem's impact require further assessment studies.
Finally, only two studies classified in the last phase of the cycle transpose to practice the measures assessed as having a positive impact and improving patient safety. These findings confirm Dentistry's participation in this area, but point to a long road ahead, suggesting fertile ground for research to help improve quality and safety in dental care.