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Are Dental Patients Concerned About Safety? An Exploratory Study
The Journal of EVIDENCE-BASED DENTAL PRACTICE
ORIGINAL ARTICLE
ARE DENTAL PATIENTS CONCERNED ABOUT SAFETY? AN EXPLORATORY STUDY ENIHOMO OBADAN-UDOH, DDS, MPH, Dr Med Sc, SAPNA PANWAR, BDS, MPH, ALFA-IBRAHIM YANSANE, PhD, ANURADHA NAYUDU, BDS, MPH, JASON PANG, BS, JOEL WHITE, DDS, MS, AND ELSBETH KALENDERIAN, DDS, MPH, PhD Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California San Francisco, San Francisco, CA, USA
ABSTRACT Objectives This study addresses a gap in the literature regarding dental patients’ perceptions about safety at the dental office and their attitudes toward reporting safety concerns and experiences. Methods We conducted a cross-sectional study with adult dental patients at an academic dental institution over a 6-week study period. A 16-item questionnaire was distributed to the patients to assess (1) past safety concerns and experiences during dental visits; (2) factors affecting the future reporting of safety concerns and experiences; (3) overall concern about safety at the dental office; (4) overall perceptions that patients should report of safety concerns or experiences to dental providers and staff. Results A majority (63.5%) of dental patients were concerned about safety at the dental office, although only one-third of them shared their past safety concerns or experiences with their dental providers or clinic staff. Irrespective of their past experiences, most patients (96.9%) believed that patients should report any safety concerns or experiences to the clinic. Being female, highly educated, and having poor oral health were associated with a decreased overall perception that patients should report safety concerns and experiences to dental care providers and staff. Conclusions Our findings suggest that dental patients are concerned about safety and can be valuable sources of data, when adequately engaged. The current level of patient reporting of safety concerns and/or experiences to clinic staff or care providers is not optimal for learning and improvement. Practical Implications Better patient engagement in safety activities will potentially increase our collective understanding of threats to safety. Therefore, dental clinics need to encourage patients to speak up about their safety concerns or experiences.
CORRESPONDING AUTHOR: Enihomo Obadan-Udoh, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco/ UCSF School of Dentistry, 707 Parnassus Avenue, San Francisco, CA 94143. E-mail: enihomo.obadan-udoh@ ucsf.edu
KEYWORDS Patient safety, Patient-reported outcome measures, Adverse events, Dental care
Source of Funding: This work was supported by the University of California San Francisco Academic Senate Committee on Equal Opportunity, United States. Received 20 May 2019; revised 9 December 2019; accepted 27 January 2020
J Evid Base Dent Pract 2020: [101424] 1532-3382/$36.00
INTRODUCTION
I
n recent years, researchers have explored the value of patient reporting of safety-related incidents as a way to capture information regarding adverse
ª 2020 Elsevier Inc. All rights reserved. doi: https://doi.org/10.1016/ j.jebdp.2020.101424
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The Journal of EVIDENCE-BASED DENTAL PRACTICE
events (AEs) in various health-care settings.1–15 When compared with traditional methods,11,16–18 patient reports have revealed AEs that were unnoticed or unreported by health-care professionals, missed by hospital incident–reporting systems, and not documented in patients’ medical records.1 While patient reports yield valuable information about AEs, patients often define AEs differently from health-care professionals.15,19 For example, while some care providers classify postmanagement incidents as complications, patients often see these incidents as AEs when they are unexpected or significantly impair their quality of life.15 This dichotomy between the perspectives of patients and the providers is the reason that incorporating the patient’s voice into the patient safety discussion is invaluable. At a minimum, it expands our collective understanding of AEs and humanizes the impact of these events. The literature suggests that certain types of AEs tend to be more easily identified by patients. Walton et al. showed that patients often report problems related to clinical processes or procedures, medications, and events that lead to or occur after the AE.15 Lang et al.20 also found that patients were more inclined to report “service and quality-related problems,” such as poor experiences in the doctor-patient relationship, lack of care coordination, difficulties with access to care, and breakdowns in communication among health-care professionals, which may ultimately lead to the occurrence of technical errors and AEs. In another study by Weingart et al.,7 none of the AEs reported by patients were captured through the traditional hospital incident–reporting system,7,21 and only about 55% of these patient-reported AEs were found in the medical records. With the exception of a few studies,5,6,20 most research on patient reporting of AEs have focused on hospital settings.1,2,7,21 In dentistry, only a handful of studies have evaluated the perspective of dental patients regarding safety or reporting of dental AEs.22,23 From the literature, we know that AEs occur at the dental office and typically present after the patient has concluded the dental encounter.24 This suggests that most dental care providers may not be aware that an AE occurred if the patient does not return to the dental office where the AE originated. It is therefore particularly important that dental patients are engaged in the reporting of AEs so that the profession can learn from them and design interventions that will accurately target the root causes of dental AEs, to prevent or eliminate them. As a first step, we sought to assess the perspectives of dental patients regarding safety at the dental office, including their past safety concerns and experiences. As a secondary objective, we evaluated the factors that affected the reporting of their past safety experiences and their
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overall perceptions about reporting safety concerns in the future.
METHODS We conducted a cross-sectional study with adult dental patients at an academic dental institution over a 6-week study period (July-August 2017). A convenience sampling technique was used to identify participants in the waiting area. Only patients who were (1) adults (aged .18 years); (2) English, Spanish, or Mandarin-speaking; and (3) had at least one prior dental visit at this dental center were included in the study. Participants were excluded if they presented for an emergency procedure or were in obvious pain. Implied consent was obtained when participants agreed to complete the survey. All responses were anonymous, and ethical approval was obtained from the relevant institutional review board (IRB#17-21467).
Survey Instrument A 16-item questionnaire was developed for this study. The instrument comprised of two main sections, Section 1 Biographic data (five questions) and Section 2 Patient Safety at the Dental Office (11 questions). Face validity was performed to evaluate dental patients’ (n 5 50) comprehension of the questions, questionnaire length, and suggestions for modifications. Overall, patients were satisfied with the assessed criteria and suggested modifications to the instructions for the questions related to race/ethnicity and primary languages spoken. Content validity was also assessed among three general dentists to determine if the questions accurately captured the intended research question. It was recommended that all references to family member experiences be removed because it could create ambiguity in the patient responses. More emphasis was also placed on the referenced timeframe (last three dental visits) in the introduction, and a distinction between the patient’s potential various care providers was added.
Outcome Measures The primary outcome was 1) past safety concerns and experiences during dental visits (Section 2, Q1, Q2, and Q3 combined). The secondary outcomes were 2) factors affecting the future reporting of safety concerns and experiences (Section 2, Q7); 3) overall concern about safety at the dental office (Section 2, Q8); 4) overall perception that patients should report safety concerns/experiences to dental providers and staff (Section 2, Q9).
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Data Analysis Descriptive statistics (counts, percentages, and 95% confidence intervals) were obtained for all discrete variables. Bivariate analyses were performed using Pearson’s Chi-square or Fisher’s exact tests to assess the relationship between patient characteristics and their past safety concerns or experiences (outcome 1), overall concern about safety (outcome 3), and overall perception about patient reporting of safety concerns or experiences to dental providers and staff (outcome 4). Multivariable analyses were performed using generalized linear models with robust variance estimates (Poisson family) to examine these outcomes while controlling for age, gender, race, educational level, primary language spoken at home, self-reported oral health status, and satisfaction with the last dental visit. Free texts from Q4 were extracted and are presented verbatim in Box 1. Free texts from Q5-7 were coded using labels that described the patients’ words (open coding). Related codes were then merged into broad categories that described one of the available responses for that question. For example, the free texts from Q6 that stated “No mechanism for doing so” or “now I know” were recategorized as response option 3 “I was not aware that I could report it”. Additional categories were created if the free text label did not fit the existing responses. For example, “the nature of a learning environment” was added as a new category for not reporting past safety concerns or experiences.
RESULTS Of the 715 patients who were invited to participate in the study, 488 patients returned a completed questionnaire (68.3% response rate). Table 1 shows the demographic distribution of all participants. Most participants were female (50.6%), Caucasian (42.5%), and aged 45-64 years (35.6%). Approximately two-thirds (67.9%) reported English as their primary language, had at least a college degree (62.2%), and rated their oral health status as “good” or “excellent” (66.6%). Of the 715 patients, 92.3% reported either being “satisfied” or “extremely satisfied” with their last dental visit. Regarding their past safety concerns and experiences during their last three dental visits (outcome 1), 1 in 6 participants (16.3%) was concerned about the safety of dental care received, 6.2% believed that they were accidently hurt, and 8.3% believed that a mistake was made during their dental visit (Figure 1). Box 1 provides some examples of the past safety concerns and experiences reported by participants. These experiences included needlestick injuries, soft-tissue lacerations, failed temporary or permanent crown, ill-fitting dentures despite multiple repair attempts, infections, to mention a few. Some patients also described
Box 1. Examples of past safety experiences and concerns by dental patients. “My student drilled into my tongue twice and didn’t make corrections promptly as recommended by the faculty” “When I was still a member of [redacted], I still remember the time when 2 students were working on a filling, paying no attention to the way they were pulling my jaw open, [they] left my jaw aching for a week” “Temp crown poorly attached and fell of within 6 hours, perm crown had to be recast” “Student was using instrument while pulling corner of my mouth, caused discomfort, student also held sharp tool close to my face, poking me for several instances” “Student did not identify my bridge properly, thought it was 5 1 [when] it was only 3” “New crown being prepped could not open my mouth more than a 1/4 in for 2 weeks- now that crown is done haven’t been able to chew on it for almost 3 months, they can’t figure out why yet!” “My permanent wire (retainer) was severed during a cleaning” “Incomplete root canal- could not get scheduled for over 30 days due to student scheduling. The tooth broke before the appointment and so the tooth was lost as well as the time and effort and pain of the partially complete procedure.” “Did not answer note; dental provider has maintained a serious persistent cough; no mask used, however, used elbow” “When I was getting my tooth pulled, the student that was in training didn’t give anesthesia [or it] was not set in at the time the tooth was being pulled it was very uncomfortable” “When extracting a molar, I believe the tooth next to that molar was ‘scratched’ because now I have a lot of sensitivity on that tooth”
service-related/quality issues such as multiple or repeat visits to repair faulty prostheses or discrepancies between quoted prices and the final cost of treatment. Of the 107 participants who responded in the affirmative to either a past safety concern or unsafe experience or both, 70.1% shared this with someone else, for example, treating care provider or provider’s supervisor (24.1%), staff member
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Table 1. Demographic characteristics of survey participants.
Table 1. Continued
95% Confidence interval Demographic characteristics Total
Frequency 488
Percent Lower Upper (%) (%) (%) 100
95% Confidence interval Demographic characteristics
Frequency
Percent Lower Upper (%) (%) (%)
Oral health status
Gender
Good or excellent
307
66.6
62.1
70.8
Fair or poor
154
33.4
29.2
37.9
434
92.3
89.6
94.4
Male
229
48.1
43.6
52.6
Female
247
51.9
47.3
56.4
18-44 years
181
37.5
33.3
41.9
Very satisfied or satisfied
45-64 years
172
35.6
31.5
40.0
Neither
19
4.0
2.6
6.3
65 years and above
130
26.9
23.1
31.1
Very dissatisfied or dissatisfied
17
3.6
2.3
5.7
White
197
42.9
38.5
47.5
Asian
90
19.6
16.2
23.5
Black/African American
67
14.6
11.6
18.1
AI/AN/NH/OPI
18
3.9
2.5
6.1
Hispanic/Latino
87
19.0
15.6
22.8
#High school
111
23.3
19.7
27.3
#Bachelor’s degree
296
62.2
57.7
66.4
69
14.5
11.6
18.0
322
67.9
63.6
72.0
Chinese (all varieties)
39
8.2
6.1
11.1
Spanish
64
13.5
10.7
16.9
Other
49
10.3
7.9
13.4
Satisfaction with last dental visit
Age
Race
Educational level
$Master’s degree
Primary language spoken at home English
(continued )
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AI, American Indian; AN, Alaskan Native; NH, Native Hawaiian; OPI, Other Pacific Islander.
(6.9%), or friend or family or coworker (39.1%). Only one patient completed the institution’s patient complaint form, which got lost to follow-up. Among those who did not share this concern or experience with the dental clinic, about 1 in 7 patients reported that the clinic was already aware of the incident, so reporting was unnecessary. The top two reasons for not sharing their past AE experiences or concerns with dental care providers and staff were not wanting to be perceived as “difficult patients” or a perceived lack of severity. Interestingly, a lack of awareness about the proper reporting protocol, potential punishment of student providers, dissatisfaction with the clinic’s past handling of incidents, and the fear of retribution did not rank very highly among the response options. Only one patient attributed their lack of reporting to a “lack of time.” Irrespective of their past experiences and actions, “significant pain or injury” was identified as the most important factor that would influence the decision to share this experience with the dental clinic in the future (outcome 2). Unplanned financial costs, unplanned visits, and the impact on their quality of life were other significant factors noted as potentially influencing patient reporting in the future. Most participants (63.5%) believed that safety was a concern at the dental clinic (outcome 3), and almost all participants (96.9%) believed that dental patients should report any
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 1. Overview of dental patients’ past safety concerns, experiences, and overall perception about patient reporting of safety incidents.
Overall perception that patients should report safety concerns and experiences to dental providers and staff
96.9
Overall concern about safety at the dental office
63.5
Concern about safety during past dental visits
16.3
Mistakes during past dental visits
8.3
Accidental injury during past dental visits
6.2
100 90 80 70 60 50 40 30 20 10
0
safety concerns or experiences to the dental clinic (provider or staff) (outcome 4). Bivariate analyses (Table 2) revealed significant associations of race, educational level, and satisfaction with last dental visit and a past safety concern or experience. Primary language spoken at home was marginally significant (P value 5 .06) for having a past safety concern or experience but significant for overall concern about safety (P value 5 .02). Primary language spoken at home, educational level, and oral health status were significantly associated with the overall perception about patient reporting of safety concerns or experiences. Multivariable analyses using generalized linear model revealed that race, AI/AN/NH/OPI1 (adjusted prevalence ratio [aPR] 5 1.21 [1.11-1.32]), was associated with a 1 AI 5 American Indian; AN 5 Alaskan Native; NH 5 Native Hawaiian; OPI 5 Other Pacific Islander.
Percentage
higher probability of having a past safety concern or experience, and a dissatisfaction with one’s last dental visit (aPR 5 0.34 [0.13-0.87]) was associated with a lower probability of having a past safety concern or experience (outcome 1; Table 3). Being female (aPR 5 0.96 [0.940.99]), having a master’s degree or higher (aPR 5 0.94 [0.90-0.99]), and having fair or poor oral health status (aPR 5 0.97 [0.95-0.99]) were associated with a reduced overall perception that patients should report safety concerns and experiences to dental care providers and staff, while speaking Spanish at home (aPR 5 1.10 [1.00-1.22]) had the reverse association, although this was only marginally significant (outcome 4; Table 3). It is important to note that as an overwhelming majority of patients had an overall perception that patients should report safety concerns and experiences to dental care providers and staff, the observed differences between groups represent the subtle variations in the probability among those without this perception.
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Table 2. Relationship between patient characteristics and outcome measures (bivariate analysis).
Patient characteristics
Outcome 1 Outcome 3 (N 5 488) (N 5 449)
Outcome (N 5 444)
Frequency (%)
Frequency (%)
Frequency (%)
107 (21.9)
285 (63.5)
430 (96.9)
Table 2. Continued
Patient characteristics Other
Yes (Q1-3, 8, 9)
Outcome 1 Outcome 3 (N 5 488) (N 5 449)
Outcome (N 5 444)
Frequency (%)
Frequency (%)
Frequency (%)
14 (13.6)
30 (10.7)a
38 (9)a
Oral health status Gender 182 (66.4)
274 (65.5)a
42 (40.8)
133 (47.7)
198 (47.1)
Good or excellent
62 (62.6)
Male Female
61 (59.2)
146 (52.3)
222 (52.9)
Fair or poor
37 (37.4)
92 (33.6)
144 (34.5)a
85 (83.3)a
259 (92.8)
393 (93.1)
5 (4.9)a
12 (4.3)
15 (3.6)
12 (11.8)a
8 (2.9)
14 (3.3)
Age 18-44 years
Satisfaction with the last dental visit 36 (34.3)
45-64 years
42 (40)
65 years and older
27 (25.7)
97 (34.3)
158 (37)
111 (39.2)
155 (36.3)
Very satisfied or satisfied
75 (26.5)
114 (26.7)
Neither Very dissatisfied or dissatisfied
Race White
35 (34.6)a
126 (46)
184 (45.4)
Asian
a
29 (28.7)
57 (20.8)
73 (18)
Black/African American
13 (12.9)a
40 (14.6)
59 (14.6)
12 (4.4)
17 (4.2)
23 (22.8)a
39 (14.2)
72 (17.8)
#High school
21 (20.8)a
55 (19.6)
85 (20)a
#Bachelor’s degree
73 (72.3)a
185 (65.8)
273 (64.4)a
7 (6.9)a
41 (14.6)
66 (15.6)a
AI/AN/NH/OPI Hispanic/Latino
1 (1)a
AI, American Indian; AN, Alaskan Native; NH, Native Hawaiian; OPI, Other Pacific Islander. Outcome 1: past safety concerns and experiences during last three dental visits (Section 2, Q1, Q2, and Q3 combined). Outcome 3: overall concern about safety at the dental office (Section 2, Q8). Outcome 4: overall perceptions about patient reporting of safety concerns/experiences with dental providers and staff (Section 2, Q9). a Statistical significance (P value , .05) based on Chi-square or Fishers’ exact tests.
Educational level
$Master’s degree Primary language spoken at home
202 (71.9)a 304 (72.4)a
English
62 (60.2)
Chinese (all varieties)
12 (11.7)
24 (8.5)a
28 (6.7)a
Spanish
15 (14.5)
25 (8.9)a
50 (11.9)a (continued )
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In summary, the main findings from this study are as follows: (1) Dental patients are concerned about safety at the dental office, and a majority believe that these concerns should be shared with dental office staff and care providers; (2) dental patients only shared their past safety concerns and experiences with dental office staff or care providers about onethird of the time; (3) the severity of the event and the fear of being perceived as “difficult patients” were the two most commonly reported factors that affected their decision to share these safety concerns and experiences; (4) significant injury or pain would affect patients’ decisions to share safety experiences with dental care providers and staff in the future; (5) gender (female), educational level (master’s degree or higher), and oral health status (fair or poor) were associated with a reduced overall perception that patients should report safety concerns and experiences to dental care providers and staff.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Table 3. Relationship between patient characteristics and outcome measures (multivariable analysis). Outcome 1 Patient characteristics Intercept
aPR (95% CI)
Outcome 3 P value
0.94 (0.78-1.13)
aPR (95% CI)
Outcome 4 P value
1.09 (1.02-1.15)
aPR (95% CI)
P value
1.41 (1.25-1.58)
Gender Male Female
Ref (2) 0.97 (0.88-1.08)
Ref (2) 0.61
0.98 (0.92-1.05)
Ref (2) 0.62
0.97 (0.94-0.99)
0.01a
Age 18-44 years
Ref (2)
Ref (2)
Ref (2)
45-64 years
0.92 (0.81-1.04)
0.19
0.92 (0.85-1.00)
0.06
0.99 (0.96-1.02)
0.37
65 years and older
0.97 (0.79-1.08)
0.64
1.00 (0.92-1.10)
0.93
1.00 (0.97-1.04)
0.82
Race White
Ref (2)
Ref (2)
Ref (2)
Asian
0.83 (0.67-1.02)
0.07
0.94 (0.84-1.06)
0.34
0.98 (0.95-1.01)
0.10
Black/African American
0.92 (0.79-1.08)
0.29
1.00 (0.90-1.12)
0.95
1.02 (0.97-1.07)
0.42
AI/AN/NH/OPI
1.21 (1.11-1.32)
0.00a
0.99 (0.83-1.19)
0.91
1.04 (0.93-1.16)
0.52
Hispanic/Latino
0.94 (0.74-1.20)
0.63
1.04 (0.90-1.21)
0.58
0.97 (0.91-1.02)
0.20
Educational level #High school
Ref (2)
Ref (2)
Ref (2)
#Bachelor’s degree
0.90 (0.78-1.03)
0.12
0.99 (0.90-1.08)
0.75
0.95 (0.91-1.00)
0.06
$Master’s degree
1.08 (0.93-1.26)
0.31
1.01 (0.89-1.15)
0.88
0.94 (0.90-0.99)
0.02a
Primary language spoken at home English
Ref (2)
Ref (2)
Ref (2)
Chinese (all varieties)
0.89 (0.63-1.26)
0.52
0.92 (0.78-1.07)
0.28
1.01 (0.99-1.04)
0.25
Spanish
0.93 (0.70-1.23)
0.60
1.10 (0.94-1.30)
0.24
1.10 (1.00-1.22)
0.05a
Other
0.97 (0.78-1.20)
0.75
0.95 (0.83-1.08)
0.43
1.07 (0.99-1.16)
0.10
Oral health status Good or excellent
Ref (2)
Ref (2)
Ref (2) (continued )
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Table 3. Continued Outcome 1 Patient characteristics Fair or poor
Outcome 3
Outcome 4
aPR (95% CI)
P value
aPR (95% CI)
P value
aPR (95% CI)
P value
1.02 (0.92-1.14)
0.68
1.01 (0.94-1.09)
0.75
0.97 (0.95-0.99)
0.01a
Satisfaction with the last dental visit Very satisfied or satisfied
Ref (2)
Ref (2)
Ref (2)
Neither
0.89 (0.65-1.21)
0.45
0.93 (0.78-1.11)
0.43
1.06 (0.95-1.19)
0.30
Very dissatisfied or dissatisfied
0.34 (0.13-0.87)
0.03a
1.08 (0.86-1.34)
0.51
0.98 (0.95-1.02)
0.37
aPR, adjusted prevalence ratio; AI, American Indian; AN, Alaskan Native; CI, confidence interval; NH, Native Hawaiian; OPI, Other Pacific Islander. Outcome 1: past safety concerns and experiences during last three dental visits (Section 2, Q1, Q2, and Q3 combined). Outcome 3: overall concern about safety at the dental office (Section 2, Q8). Outcome 4: overall perceptions that patients shoud report safety concerns or experiences to dental providers and staff (Section 2, Q9). a
Statistical significance (P value , .05) based on generalized linear models (GLM) with robust variance estimates (Poisson family).
DISCUSSION 25,26
It is no secret that AEs occur in health care, and the recent statistics emerging from dentistry confirm this observation.22,27–32 This study addresses a gap in the literature regarding dental patients’ perceptions about safety at the dental clinic and their reporting of safety concerns and/or experiences. Our findings suggest that dental patients can be a valuable source of information about the safety of our dental clinics; however, their level of engagement to promote safety is not currently optimal. Patients reported various reasons for not sharing their past AE experiences and safety concerns with the dental staff and care providers, including a fear of being perceived as difficult patients or retribution when seeking future dental care, which underscores the need for more research with dental patients to fully understand the basis for these fears and to develop strategies for overcoming them. This absence of a feedback loop between the dental clinic and dental patient has limited our ability to learn from past mistakes and to identify potential hazards or threats to safety. For example, only one patient made a formal complaint but never received any follow-up. Patients need to trust that we will take their concerns seriously and take steps to effectively address those concerns. Furthermore, dental clinics need to proactively solicit patient feedback about their safety concerns and experiences rather than reacting to patient-initiated complaints to become true learning health systems.33 With advancements in technology and the avalanche of personal devices, opportunities now exist to engage dental patients directly and in more meaningful ways.34–36 Patients already use generic online community platforms such as
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Yelp, Zocdoc, and Google to read and/or post reviews about their health-care providers and experiences with the health-care system, albeit in an unstructured manner.37–39 These reviews also tend to focus on the extremes of experiences, that is, exceptional or very poor-quality dental care, and may not contain enough useful information to enable learning.38 Some researchers have sought to harness this “wisdom of the crowd” potential through platforms such as HealthTalkOnline.org, which synthesizes patients’ everyday experiences into searchable topics that enable learning.40,41 Dental professionals can also tap into the wisdom of their patients by developing these types of online platforms for sharing of safety experiences and concerns in a standardized manner. This guided use of social media can potentially enhance learning for qualityimprovement purposes. Indeed, researchers have analyzed data from social media and online platforms to improve trust in dental provider rankings/matching with patients,42–44 to understand gaps in patient knowledge as well as their use for peer support or learning about dental diseases,45 and to explain patient behaviors related to dental conditions.46 Rather than responding defensively to patients’ use of social media and online platforms, care providers could work collaboratively with patients to identify credible internet-based sources of health information and develop tools for filtering their content.47 A variety of Web-based reporting systems have been used successfully by our medical colleagues to capture information about errors and AEs.48–51 While most of these reporting systems have been targeted toward care providers and staff, a few have sought to capture patient reports as well.52–54 For example, a study of patient reports
The Journal of EVIDENCE-BASED DENTAL PRACTICE
to the United Kingdom’s Yellow Card Scheme revealed that patients provided more detailed descriptions of their adverse drug reactions than health-care providers and often provided pertinent details regarding the causes and impact of these adverse drug reactions on their lives.55 These patient reports often led to improved pharmacovigilance by enhancing signal generation and detection.55 Dentistry can learn from the successes (and challenges) of these patient-based incident-reporting systems as we seek to develop our system and/or modify existing systems such as the Dental Patient Safety Foundation’s Web-based incident-reporting system (https:// www.dentalpatientsafety.org/) for care providers. Ideally, a user-friendly, and cross-platform, that is, mobile and desktop system, which provides periodic reports on submitted events, will offer the greatest utility for patient engagement and care provider learning. As observed in our study, some factors that affected the reporting of past safety experiences and concerns included the fear of being perceived as difficult patients and the severity of the incident. Patients have been shown to generally abstain from being confrontational about safety and often prefer to ask factual questions rather than challenging ones.56 Unplanned financial costs, unplanned visits, and the impact on their quality of life were other significant factors noted as potentially influencing patient reporting to dental providers and staff in the future. Although dental patients were not more prone to sharing their past safety concerns and experiences with dentists compared with other clinic staff, one out of every ten patients (11.8%) reported that they would be more likely to share their safety concerns or experiences if their care provider asks them about it, which aligns with observations by Davis et al. that showed the willingness of patients to participate in safety increased with provider encouragement.56 The relationship between race and patient safety has been relatively underexplored and mixed because of minority populations being underrepresented in most safety studies.57 Owing to the limited number of observations, the finding that persons belonging to the “AI/AN/NH/ OPI” racial category had a higher probability of having a past safety concern or experience than the “white” racial category, while other racial groups had lower probabilities, warrants further exploration in future research studies with larger sample sizes. Overall, patients were generally supportive of the concept of reporting safety experiences and concerns irrespective of their past actions. This aligns with findings by our medical colleagues.58–61 However, they need to be educated about their roles, empowered to speak up through direct encouragement by care providers/clinic staff, and engaged in a meaningful manner; for example, through the use of health information technology.34–36 Conversely, although Davis
et al. found that being female, younger, and more educated increased the willingness to be engaged in safety-related activities,61 this was not observed in our study sample. Instead being female and more educated were associated with a reduced overall perception that patients should report safety concerns and experiences to dental care providers and staff. One explanation for this observation in our study population might be their empathy for the nature of a training environment and a disposition toward protecting their student care providers from the negative consequences associated with a patient complaint. Furthermore, self-reported poor oral health status was significantly associated with a lower predisposition toward patient reporting of safety incidents to care providers, which aligns with findings from our previous study in South Africa that found a significant association between having a past dental AE experience and dissatisfaction with oral health status.22 The finding that Spanish-speaking patients were significantly more likely to have an overall perception that patients should report safety concerns and experiences to dental care providers and staff was unexpected and deserves further exploration because this has not been previously documented, and the Latino population has been relatively underrepresented in most patient safety studies.57 This study assessed the past experiences and reporting of safety incidents by dental patients, their perceptions toward future reporting, and role as potential partners in promoting safety. It provides a baseline that establishes the magnitude of the problem from the patients’ perspective and informs the design of future research studies that will seek to better engage patients in safety reporting to determine the incidence of dental AEs and their related events. Our study has several limitations. First, the use of a survey approach may have limited our ability to capture the subtle nuances and to gain a comprehensive understanding of the reasons behind past behaviors by dental patients. Qualitative studies were also conducted concurrently to provide patients with some more opportunity to expand upon their past safety concerns and experiences, and those results are discussed elsewhere. Second, although participants represented a diverse pool of patients, participants were limited to a single site which limits the generalizability of our study findings. Third, only nonemergency patients were included, which might have systematically excluded a cohort of patients that were more likely to experience AEs. Finally, none of the patient reports were validated with their care providers or dental records. Although, given the limited number of patients who shared these experiences with the clinic staff or care providers, it would be reasonable to assume a low concordance between both sources of data, hence underscoring the need to capture the patient’s experiences directly from the patients.
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CONCLUSION Most dental patients are concerned about safety at the dental clinic, and although only a third of them shared their past concerns or experiences with their dental care providers or clinic staff, most patients believe that patients should report these concerns and experiences to the clinic staff. Being female, highly educated, and having poor oral health were associated with a decreased overall perception that patients should report safety concerns and experiences to dental care providers and staff.
ACKNOWLEDGMENT Author contributions: E.O.-U. contributed to conceptualization, funding acquisition, methodology, project administration, resources, supervision, validation, and visualization. S.P. performed data curation. S.P. and A.-I.Y. performed a formal analysis. E.O.-U. and S.P. prepared the original draft. S.P. and A.-I.Y. chose the software programs used in the study. A.N. and J.P. contributed to investigations carried out in the study. All authors contributed to reviewing and editing the article.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi.org/10.1016/j.jebdp.2020.101424.
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The Journal of EVIDENCE-BASED DENTAL PRACTICE 23. Jonsson L, Gabre P. Adverse events in Public Dental Service in a Swedish county–a survey of reported cases over two years. Swed Dent J 2014;38(3):151-60. 24. Obadan EM, Ramoni RB, Kalenderian E. Lessons learned from dental patient safety case reports. J Am Dent Assoc 2015;146(5):318-326.e2. 25. National Academies of Sciences E, Medicine. Crossing the Global Quality Chasm: Improving Health Care Worldwide. Washington, DC: The National Academies Press; 2018. 26. Classen DC, Resar R, Griffin F, et al. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood) 2011;30(4):581-9. 27. Kalenderian E, Obadan-Udoh E, Yansane A, et al. Feasibility of electronic health record-based triggers in detecting dental adverse events. Appl Clin Inform 2018;9(3):646-53. 28. Tokede O, Walji M, Ramoni R, et al. Quantifying dental officeoriginating adverse events: the dental practice study methods. J Patient Saf; 2017. [epub ahead of print]. https://doi. org/10.1097/PTS.0000000000000444. 29. Hiivala N, Mussalo-Rauhamaa H, Murtomaa H. Patient safety incidents reported by Finnish dentists; results from an internetbased survey. Acta Odontol Scand 2013;71(6):1370-7. 30. Thusu S, Panesar S, Bedi R. Patient safety in dentistry - state of play as revealed by a national database of errors. Br Dent J 2012;213(3):E3. 31. Kalenderian E, Walji MF, Tavares A, Ramoni RB. An adverse event trigger tool in dentistry: a new methodology for measuring harm in the dental office. J Am Dent Assoc 2013;144(7):808-14. 32. Ramoni RB, Walji MF. Kalenderian E Safety in Dentistry. Perspectives on Safety. Agency for Healthcare Research and Quality; 2016. Available at: https://psnet.ahrq.gov/perspective/ safety-dentistry. Accessed March 31, 2020. 33. McGinnis JM, Stuckhardt L, Saunders R, Smith M. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. National Academies Press: Washington, DC.; 2013. 34. Wasson JH, Forsberg HH, Lindblad S, et al. The medium is the (health) measure: patient engagement using personal technologies 2012;35(2):109-17. 35. LoPresti M, Appelboom G, Bruyère O, et al. Patient engagement in clinical research through mobile technology 2014;11(6):549. 36. Ricciardi L, Mostashari F, Murphy J, Daniel JG, Siminerio EP. A national action plan to support consumer engagement via e-health. Health Aff 2013;32(2):376-84. 37. López A, Detz A, Ratanawongsa N, Sarkar U. What patients say about their doctors online: a qualitative content analysis. J Gen Intern Med 2012;27(6):685-92. 38. Ranard BL, Werner RM, Antanavicius T, et al. Yelp reviews of hospital care can supplement and inform traditional surveys of the patient experience of care. Health Aff 2016;35(4):697-705.
39. Kadry B, Chu LF, Kadry B, Gammas D, Macario A. Analysis of 4999 online physician ratings indicates that most patients give physicians a favorable rating. J Med Internet Res 2011;13(4): e95. 40. Basch E. New frontiers in patient-reported outcomes: adverse event reporting, comparative effectiveness, and quality assessment. Annu Rev Med 2014;65:307-17. 41. Basch E, Dueck AC, Rogak LJ, et al. Feasibility assessment of patient reporting of symptomatic adverse events in multicenter cancer clinical trials. JAMA Oncol 2017;3:1043-50. 42. Pradhan S, Gay V, Nepal S. Analysing and Using Subjective Criteria to Improve Dental Care Recommendation Systems. Paper presented at: Pacific Asia Conference on Information Systems, PACIS, 2015; Singapore. 43. Pradhan S, Gay V, Nepal S. Social Networking and Dental Care: State of the Art and Analysis of the Impact on Dentists, Dental Practices and Their Patients. 26th Bled eConferenceeInnovations: Challenges and Impacts for Individuals, Organizations and Society. Slovenia: Bled; 2013. 44. Pradhan S, Gay V, Nepal S. Improving the Matching Process of Dental Care Recommendation Systems by Using Subjective Criteria for Both Patients and Dentists. Paper presented at: Pacific Asia Conference on Information Systems, PACIS 2014; Chengdu, China. 45. Barber SK, Lam Y, Hodge TM, Pavitt S. Is social media the way to empower patients to share their experiences of dental care? J Am Dental Assoc 2018;149(6):451-459. e9. 46. Heaivilin N, Gerbert B, Page JE, Gibbs JL. Public health surveillance of dental pain via Twitter 2011;90(9):1047-51. 47. McMullan M. Patients using the Internet to obtain health information: how this affects the patient–health professional relationship. Patient Educ Couns 2006;63(1):24-8. 48. Flott K, Radcliff N, Fontana G, et al. Improving patient safety incident reporting? There is an App for that. Health Affairs Blog, July 1, 2015. https://doi.org/10.1377/hblog20150701.048962. Accessed March 31, 2020. 49. Hoffmann B, Beyer M, Rohe J, Gensichen J, Gerlach FM. “Every error counts”: a web-based incident reporting and learning system for general practice. Qual Saf Health Care 2008;17(4): 307-12. 50. Atherton T. Description and outcomes of the DoctorQuality incident reporting system used at Baylor Medical Center at Grapevine. Proc (Bayl Univ Med Cent) 2002;15(2):203-11. 51. Brown CA, Bailey JH, Miller Davis ME, Garrett P, Rudman WJ. Improving patient safety through information technology. Perspect Health Inf Manag 2005;2. 5-5. 52. Inacio P, Cavaco A, Airaksinen M. The value of patient reporting to the pharmacovigilance system: a systematic review. Br J Clin Pharmacol 2017;83(2):227-46. 53. Toki T, Ono S. Spontaneous reporting on adverse events by consumers in the United States: an analysis of the food and
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57. Okoroh JS, Uribe EF, Weingart S. Racial and ethnic disparities in patient safety. J Patient Saf 2017;13(3):153-61.
54. Bahk CY, Goshgarian M, Donahue K, et al. Increasing patient engagement in pharmacovigilance through online community outreach and mobile reporting applications: an analysis of adverse event reporting for the essure device in the US. Pharmaceut Med 2015;29(6):331-40.
58. Ringdal M, Chaboyer W, Ulin K, Bucknall T, Oxelmark L. Patient preferences for participation in patient care and safety activities in hospitals. BMC Nurs 2017;16:69.
55. Avery AJ, Anderson C, Bond CM, et al. Evaluation of patient reporting of adverse drug reactions to the UK ‘Yellow Card Scheme’: literature review, descriptive and qualitative analyses, and questionnaire surveys. Health Technol Assess 2011;15(20): 1-234, iii-iv. 56. Davis RE, Koutantji M, Vincent CA. How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study. Qual Saf Health Care 2008;17(2):90-6.
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59. Duhn L, Medves J. A 5-facet framework to describe patient engagement in patient safety. Health Expect 2018;21(6): 1122-33. 60. Davis RE, Jacklin R, Sevdalis N, Vincent CA. Patient involvement in patient safety: what factors influence patient participation and engagement? Health Expect 2007;10(3):259-67. 61. Davis RE, Sevdalis N, Vincent CA. Patient involvement in patient safety: how willing are patients to participate? BMJ Qual Saf 2011;20(1):108-14.
ORIGINAL ARTICLE
ARE DENTAL PATIENTS CONCERNED ABOUT SAFETY? AN EXPLORATORY STUDY ENIHOMO OBADAN-UDOH, DDS, MPH, Dr Med Sc, SAPNA PANWAR, BDS, MPH, ALFA-IBRAHIM YANSANE, PhD, ANURADHA NAYUDU, BDS, MPH, JASON PANG, BS, JOEL WHITE, DDS, MS, AND ELSBETH KALENDERIAN, DDS, MPH, PhD Department of Preventive and Restorative Dental Sciences, School of Dentistry, University of California San Francisco, San Francisco, CA, USA
ABSTRACT Objectives This study addresses a gap in the literature regarding dental patients’ perceptions about safety at the dental office and their attitudes toward reporting safety concerns and experiences. Methods We conducted a cross-sectional study with adult dental patients at an academic dental institution over a 6-week study period. A 16-item questionnaire was distributed to the patients to assess (1) past safety concerns and experiences during dental visits; (2) factors affecting the future reporting of safety concerns and experiences; (3) overall concern about safety at the dental office; (4) overall perceptions that patients should report of safety concerns or experiences to dental providers and staff. Results A majority (63.5%) of dental patients were concerned about safety at the dental office, although only one-third of them shared their past safety concerns or experiences with their dental providers or clinic staff. Irrespective of their past experiences, most patients (96.9%) believed that patients should report any safety concerns or experiences to the clinic. Being female, highly educated, and having poor oral health were associated with a decreased overall perception that patients should report safety concerns and experiences to dental care providers and staff. Conclusions Our findings suggest that dental patients are concerned about safety and can be valuable sources of data, when adequately engaged. The current level of patient reporting of safety concerns and/or experiences to clinic staff or care providers is not optimal for learning and improvement. Practical Implications Better patient engagement in safety activities will potentially increase our collective understanding of threats to safety. Therefore, dental clinics need to encourage patients to speak up about their safety concerns or experiences.
CORRESPONDING AUTHOR: Enihomo Obadan-Udoh, Department of Preventive and Restorative Dental Sciences, University of California, San Francisco/ UCSF School of Dentistry, 707 Parnassus Avenue, San Francisco, CA 94143. E-mail: enihomo.obadan-udoh@ ucsf.edu
KEYWORDS Patient safety, Patient-reported outcome measures, Adverse events, Dental care
Source of Funding: This work was supported by the University of California San Francisco Academic Senate Committee on Equal Opportunity, United States. Received 20 May 2019; revised 9 December 2019; accepted 27 January 2020
J Evid Base Dent Pract 2020: [101424] 1532-3382/$36.00
INTRODUCTION
I
n recent years, researchers have explored the value of patient reporting of safety-related incidents as a way to capture information regarding adverse
ª 2020 Elsevier Inc. All rights reserved. doi: https://doi.org/10.1016/ j.jebdp.2020.101424
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events (AEs) in various health-care settings.1–15 When compared with traditional methods,11,16–18 patient reports have revealed AEs that were unnoticed or unreported by health-care professionals, missed by hospital incident–reporting systems, and not documented in patients’ medical records.1 While patient reports yield valuable information about AEs, patients often define AEs differently from health-care professionals.15,19 For example, while some care providers classify postmanagement incidents as complications, patients often see these incidents as AEs when they are unexpected or significantly impair their quality of life.15 This dichotomy between the perspectives of patients and the providers is the reason that incorporating the patient’s voice into the patient safety discussion is invaluable. At a minimum, it expands our collective understanding of AEs and humanizes the impact of these events. The literature suggests that certain types of AEs tend to be more easily identified by patients. Walton et al. showed that patients often report problems related to clinical processes or procedures, medications, and events that lead to or occur after the AE.15 Lang et al.20 also found that patients were more inclined to report “service and quality-related problems,” such as poor experiences in the doctor-patient relationship, lack of care coordination, difficulties with access to care, and breakdowns in communication among health-care professionals, which may ultimately lead to the occurrence of technical errors and AEs. In another study by Weingart et al.,7 none of the AEs reported by patients were captured through the traditional hospital incident–reporting system,7,21 and only about 55% of these patient-reported AEs were found in the medical records. With the exception of a few studies,5,6,20 most research on patient reporting of AEs have focused on hospital settings.1,2,7,21 In dentistry, only a handful of studies have evaluated the perspective of dental patients regarding safety or reporting of dental AEs.22,23 From the literature, we know that AEs occur at the dental office and typically present after the patient has concluded the dental encounter.24 This suggests that most dental care providers may not be aware that an AE occurred if the patient does not return to the dental office where the AE originated. It is therefore particularly important that dental patients are engaged in the reporting of AEs so that the profession can learn from them and design interventions that will accurately target the root causes of dental AEs, to prevent or eliminate them. As a first step, we sought to assess the perspectives of dental patients regarding safety at the dental office, including their past safety concerns and experiences. As a secondary objective, we evaluated the factors that affected the reporting of their past safety experiences and their
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overall perceptions about reporting safety concerns in the future.
METHODS We conducted a cross-sectional study with adult dental patients at an academic dental institution over a 6-week study period (July-August 2017). A convenience sampling technique was used to identify participants in the waiting area. Only patients who were (1) adults (aged .18 years); (2) English, Spanish, or Mandarin-speaking; and (3) had at least one prior dental visit at this dental center were included in the study. Participants were excluded if they presented for an emergency procedure or were in obvious pain. Implied consent was obtained when participants agreed to complete the survey. All responses were anonymous, and ethical approval was obtained from the relevant institutional review board (IRB#17-21467).
Survey Instrument A 16-item questionnaire was developed for this study. The instrument comprised of two main sections, Section 1 Biographic data (five questions) and Section 2 Patient Safety at the Dental Office (11 questions). Face validity was performed to evaluate dental patients’ (n 5 50) comprehension of the questions, questionnaire length, and suggestions for modifications. Overall, patients were satisfied with the assessed criteria and suggested modifications to the instructions for the questions related to race/ethnicity and primary languages spoken. Content validity was also assessed among three general dentists to determine if the questions accurately captured the intended research question. It was recommended that all references to family member experiences be removed because it could create ambiguity in the patient responses. More emphasis was also placed on the referenced timeframe (last three dental visits) in the introduction, and a distinction between the patient’s potential various care providers was added.
Outcome Measures The primary outcome was 1) past safety concerns and experiences during dental visits (Section 2, Q1, Q2, and Q3 combined). The secondary outcomes were 2) factors affecting the future reporting of safety concerns and experiences (Section 2, Q7); 3) overall concern about safety at the dental office (Section 2, Q8); 4) overall perception that patients should report safety concerns/experiences to dental providers and staff (Section 2, Q9).
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Data Analysis Descriptive statistics (counts, percentages, and 95% confidence intervals) were obtained for all discrete variables. Bivariate analyses were performed using Pearson’s Chi-square or Fisher’s exact tests to assess the relationship between patient characteristics and their past safety concerns or experiences (outcome 1), overall concern about safety (outcome 3), and overall perception about patient reporting of safety concerns or experiences to dental providers and staff (outcome 4). Multivariable analyses were performed using generalized linear models with robust variance estimates (Poisson family) to examine these outcomes while controlling for age, gender, race, educational level, primary language spoken at home, self-reported oral health status, and satisfaction with the last dental visit. Free texts from Q4 were extracted and are presented verbatim in Box 1. Free texts from Q5-7 were coded using labels that described the patients’ words (open coding). Related codes were then merged into broad categories that described one of the available responses for that question. For example, the free texts from Q6 that stated “No mechanism for doing so” or “now I know” were recategorized as response option 3 “I was not aware that I could report it”. Additional categories were created if the free text label did not fit the existing responses. For example, “the nature of a learning environment” was added as a new category for not reporting past safety concerns or experiences.
RESULTS Of the 715 patients who were invited to participate in the study, 488 patients returned a completed questionnaire (68.3% response rate). Table 1 shows the demographic distribution of all participants. Most participants were female (50.6%), Caucasian (42.5%), and aged 45-64 years (35.6%). Approximately two-thirds (67.9%) reported English as their primary language, had at least a college degree (62.2%), and rated their oral health status as “good” or “excellent” (66.6%). Of the 715 patients, 92.3% reported either being “satisfied” or “extremely satisfied” with their last dental visit. Regarding their past safety concerns and experiences during their last three dental visits (outcome 1), 1 in 6 participants (16.3%) was concerned about the safety of dental care received, 6.2% believed that they were accidently hurt, and 8.3% believed that a mistake was made during their dental visit (Figure 1). Box 1 provides some examples of the past safety concerns and experiences reported by participants. These experiences included needlestick injuries, soft-tissue lacerations, failed temporary or permanent crown, ill-fitting dentures despite multiple repair attempts, infections, to mention a few. Some patients also described
Box 1. Examples of past safety experiences and concerns by dental patients. “My student drilled into my tongue twice and didn’t make corrections promptly as recommended by the faculty” “When I was still a member of [redacted], I still remember the time when 2 students were working on a filling, paying no attention to the way they were pulling my jaw open, [they] left my jaw aching for a week” “Temp crown poorly attached and fell of within 6 hours, perm crown had to be recast” “Student was using instrument while pulling corner of my mouth, caused discomfort, student also held sharp tool close to my face, poking me for several instances” “Student did not identify my bridge properly, thought it was 5 1 [when] it was only 3” “New crown being prepped could not open my mouth more than a 1/4 in for 2 weeks- now that crown is done haven’t been able to chew on it for almost 3 months, they can’t figure out why yet!” “My permanent wire (retainer) was severed during a cleaning” “Incomplete root canal- could not get scheduled for over 30 days due to student scheduling. The tooth broke before the appointment and so the tooth was lost as well as the time and effort and pain of the partially complete procedure.” “Did not answer note; dental provider has maintained a serious persistent cough; no mask used, however, used elbow” “When I was getting my tooth pulled, the student that was in training didn’t give anesthesia [or it] was not set in at the time the tooth was being pulled it was very uncomfortable” “When extracting a molar, I believe the tooth next to that molar was ‘scratched’ because now I have a lot of sensitivity on that tooth”
service-related/quality issues such as multiple or repeat visits to repair faulty prostheses or discrepancies between quoted prices and the final cost of treatment. Of the 107 participants who responded in the affirmative to either a past safety concern or unsafe experience or both, 70.1% shared this with someone else, for example, treating care provider or provider’s supervisor (24.1%), staff member
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Table 1. Demographic characteristics of survey participants.
Table 1. Continued
95% Confidence interval Demographic characteristics Total
Frequency 488
Percent Lower Upper (%) (%) (%) 100
95% Confidence interval Demographic characteristics
Frequency
Percent Lower Upper (%) (%) (%)
Oral health status
Gender
Good or excellent
307
66.6
62.1
70.8
Fair or poor
154
33.4
29.2
37.9
434
92.3
89.6
94.4
Male
229
48.1
43.6
52.6
Female
247
51.9
47.3
56.4
18-44 years
181
37.5
33.3
41.9
Very satisfied or satisfied
45-64 years
172
35.6
31.5
40.0
Neither
19
4.0
2.6
6.3
65 years and above
130
26.9
23.1
31.1
Very dissatisfied or dissatisfied
17
3.6
2.3
5.7
White
197
42.9
38.5
47.5
Asian
90
19.6
16.2
23.5
Black/African American
67
14.6
11.6
18.1
AI/AN/NH/OPI
18
3.9
2.5
6.1
Hispanic/Latino
87
19.0
15.6
22.8
#High school
111
23.3
19.7
27.3
#Bachelor’s degree
296
62.2
57.7
66.4
69
14.5
11.6
18.0
322
67.9
63.6
72.0
Chinese (all varieties)
39
8.2
6.1
11.1
Spanish
64
13.5
10.7
16.9
Other
49
10.3
7.9
13.4
Satisfaction with last dental visit
Age
Race
Educational level
$Master’s degree
Primary language spoken at home English
(continued )
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AI, American Indian; AN, Alaskan Native; NH, Native Hawaiian; OPI, Other Pacific Islander.
(6.9%), or friend or family or coworker (39.1%). Only one patient completed the institution’s patient complaint form, which got lost to follow-up. Among those who did not share this concern or experience with the dental clinic, about 1 in 7 patients reported that the clinic was already aware of the incident, so reporting was unnecessary. The top two reasons for not sharing their past AE experiences or concerns with dental care providers and staff were not wanting to be perceived as “difficult patients” or a perceived lack of severity. Interestingly, a lack of awareness about the proper reporting protocol, potential punishment of student providers, dissatisfaction with the clinic’s past handling of incidents, and the fear of retribution did not rank very highly among the response options. Only one patient attributed their lack of reporting to a “lack of time.” Irrespective of their past experiences and actions, “significant pain or injury” was identified as the most important factor that would influence the decision to share this experience with the dental clinic in the future (outcome 2). Unplanned financial costs, unplanned visits, and the impact on their quality of life were other significant factors noted as potentially influencing patient reporting in the future. Most participants (63.5%) believed that safety was a concern at the dental clinic (outcome 3), and almost all participants (96.9%) believed that dental patients should report any
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Figure 1. Overview of dental patients’ past safety concerns, experiences, and overall perception about patient reporting of safety incidents.
Overall perception that patients should report safety concerns and experiences to dental providers and staff
96.9
Overall concern about safety at the dental office
63.5
Concern about safety during past dental visits
16.3
Mistakes during past dental visits
8.3
Accidental injury during past dental visits
6.2
100 90 80 70 60 50 40 30 20 10
0
safety concerns or experiences to the dental clinic (provider or staff) (outcome 4). Bivariate analyses (Table 2) revealed significant associations of race, educational level, and satisfaction with last dental visit and a past safety concern or experience. Primary language spoken at home was marginally significant (P value 5 .06) for having a past safety concern or experience but significant for overall concern about safety (P value 5 .02). Primary language spoken at home, educational level, and oral health status were significantly associated with the overall perception about patient reporting of safety concerns or experiences. Multivariable analyses using generalized linear model revealed that race, AI/AN/NH/OPI1 (adjusted prevalence ratio [aPR] 5 1.21 [1.11-1.32]), was associated with a 1 AI 5 American Indian; AN 5 Alaskan Native; NH 5 Native Hawaiian; OPI 5 Other Pacific Islander.
Percentage
higher probability of having a past safety concern or experience, and a dissatisfaction with one’s last dental visit (aPR 5 0.34 [0.13-0.87]) was associated with a lower probability of having a past safety concern or experience (outcome 1; Table 3). Being female (aPR 5 0.96 [0.940.99]), having a master’s degree or higher (aPR 5 0.94 [0.90-0.99]), and having fair or poor oral health status (aPR 5 0.97 [0.95-0.99]) were associated with a reduced overall perception that patients should report safety concerns and experiences to dental care providers and staff, while speaking Spanish at home (aPR 5 1.10 [1.00-1.22]) had the reverse association, although this was only marginally significant (outcome 4; Table 3). It is important to note that as an overwhelming majority of patients had an overall perception that patients should report safety concerns and experiences to dental care providers and staff, the observed differences between groups represent the subtle variations in the probability among those without this perception.
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Table 2. Relationship between patient characteristics and outcome measures (bivariate analysis).
Patient characteristics
Outcome 1 Outcome 3 (N 5 488) (N 5 449)
Outcome (N 5 444)
Frequency (%)
Frequency (%)
Frequency (%)
107 (21.9)
285 (63.5)
430 (96.9)
Table 2. Continued
Patient characteristics Other
Yes (Q1-3, 8, 9)
Outcome 1 Outcome 3 (N 5 488) (N 5 449)
Outcome (N 5 444)
Frequency (%)
Frequency (%)
Frequency (%)
14 (13.6)
30 (10.7)a
38 (9)a
Oral health status Gender 182 (66.4)
274 (65.5)a
42 (40.8)
133 (47.7)
198 (47.1)
Good or excellent
62 (62.6)
Male Female
61 (59.2)
146 (52.3)
222 (52.9)
Fair or poor
37 (37.4)
92 (33.6)
144 (34.5)a
85 (83.3)a
259 (92.8)
393 (93.1)
5 (4.9)a
12 (4.3)
15 (3.6)
12 (11.8)a
8 (2.9)
14 (3.3)
Age 18-44 years
Satisfaction with the last dental visit 36 (34.3)
45-64 years
42 (40)
65 years and older
27 (25.7)
97 (34.3)
158 (37)
111 (39.2)
155 (36.3)
Very satisfied or satisfied
75 (26.5)
114 (26.7)
Neither Very dissatisfied or dissatisfied
Race White
35 (34.6)a
126 (46)
184 (45.4)
Asian
a
29 (28.7)
57 (20.8)
73 (18)
Black/African American
13 (12.9)a
40 (14.6)
59 (14.6)
12 (4.4)
17 (4.2)
23 (22.8)a
39 (14.2)
72 (17.8)
#High school
21 (20.8)a
55 (19.6)
85 (20)a
#Bachelor’s degree
73 (72.3)a
185 (65.8)
273 (64.4)a
7 (6.9)a
41 (14.6)
66 (15.6)a
AI/AN/NH/OPI Hispanic/Latino
1 (1)a
AI, American Indian; AN, Alaskan Native; NH, Native Hawaiian; OPI, Other Pacific Islander. Outcome 1: past safety concerns and experiences during last three dental visits (Section 2, Q1, Q2, and Q3 combined). Outcome 3: overall concern about safety at the dental office (Section 2, Q8). Outcome 4: overall perceptions about patient reporting of safety concerns/experiences with dental providers and staff (Section 2, Q9). a Statistical significance (P value , .05) based on Chi-square or Fishers’ exact tests.
Educational level
$Master’s degree Primary language spoken at home
202 (71.9)a 304 (72.4)a
English
62 (60.2)
Chinese (all varieties)
12 (11.7)
24 (8.5)a
28 (6.7)a
Spanish
15 (14.5)
25 (8.9)a
50 (11.9)a (continued )
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In summary, the main findings from this study are as follows: (1) Dental patients are concerned about safety at the dental office, and a majority believe that these concerns should be shared with dental office staff and care providers; (2) dental patients only shared their past safety concerns and experiences with dental office staff or care providers about onethird of the time; (3) the severity of the event and the fear of being perceived as “difficult patients” were the two most commonly reported factors that affected their decision to share these safety concerns and experiences; (4) significant injury or pain would affect patients’ decisions to share safety experiences with dental care providers and staff in the future; (5) gender (female), educational level (master’s degree or higher), and oral health status (fair or poor) were associated with a reduced overall perception that patients should report safety concerns and experiences to dental care providers and staff.
The Journal of EVIDENCE-BASED DENTAL PRACTICE
Table 3. Relationship between patient characteristics and outcome measures (multivariable analysis). Outcome 1 Patient characteristics Intercept
aPR (95% CI)
Outcome 3 P value
0.94 (0.78-1.13)
aPR (95% CI)
Outcome 4 P value
1.09 (1.02-1.15)
aPR (95% CI)
P value
1.41 (1.25-1.58)
Gender Male Female
Ref (2) 0.97 (0.88-1.08)
Ref (2) 0.61
0.98 (0.92-1.05)
Ref (2) 0.62
0.97 (0.94-0.99)
0.01a
Age 18-44 years
Ref (2)
Ref (2)
Ref (2)
45-64 years
0.92 (0.81-1.04)
0.19
0.92 (0.85-1.00)
0.06
0.99 (0.96-1.02)
0.37
65 years and older
0.97 (0.79-1.08)
0.64
1.00 (0.92-1.10)
0.93
1.00 (0.97-1.04)
0.82
Race White
Ref (2)
Ref (2)
Ref (2)
Asian
0.83 (0.67-1.02)
0.07
0.94 (0.84-1.06)
0.34
0.98 (0.95-1.01)
0.10
Black/African American
0.92 (0.79-1.08)
0.29
1.00 (0.90-1.12)
0.95
1.02 (0.97-1.07)
0.42
AI/AN/NH/OPI
1.21 (1.11-1.32)
0.00a
0.99 (0.83-1.19)
0.91
1.04 (0.93-1.16)
0.52
Hispanic/Latino
0.94 (0.74-1.20)
0.63
1.04 (0.90-1.21)
0.58
0.97 (0.91-1.02)
0.20
Educational level #High school
Ref (2)
Ref (2)
Ref (2)
#Bachelor’s degree
0.90 (0.78-1.03)
0.12
0.99 (0.90-1.08)
0.75
0.95 (0.91-1.00)
0.06
$Master’s degree
1.08 (0.93-1.26)
0.31
1.01 (0.89-1.15)
0.88
0.94 (0.90-0.99)
0.02a
Primary language spoken at home English
Ref (2)
Ref (2)
Ref (2)
Chinese (all varieties)
0.89 (0.63-1.26)
0.52
0.92 (0.78-1.07)
0.28
1.01 (0.99-1.04)
0.25
Spanish
0.93 (0.70-1.23)
0.60
1.10 (0.94-1.30)
0.24
1.10 (1.00-1.22)
0.05a
Other
0.97 (0.78-1.20)
0.75
0.95 (0.83-1.08)
0.43
1.07 (0.99-1.16)
0.10
Oral health status Good or excellent
Ref (2)
Ref (2)
Ref (2) (continued )
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Table 3. Continued Outcome 1 Patient characteristics Fair or poor
Outcome 3
Outcome 4
aPR (95% CI)
P value
aPR (95% CI)
P value
aPR (95% CI)
P value
1.02 (0.92-1.14)
0.68
1.01 (0.94-1.09)
0.75
0.97 (0.95-0.99)
0.01a
Satisfaction with the last dental visit Very satisfied or satisfied
Ref (2)
Ref (2)
Ref (2)
Neither
0.89 (0.65-1.21)
0.45
0.93 (0.78-1.11)
0.43
1.06 (0.95-1.19)
0.30
Very dissatisfied or dissatisfied
0.34 (0.13-0.87)
0.03a
1.08 (0.86-1.34)
0.51
0.98 (0.95-1.02)
0.37
aPR, adjusted prevalence ratio; AI, American Indian; AN, Alaskan Native; CI, confidence interval; NH, Native Hawaiian; OPI, Other Pacific Islander. Outcome 1: past safety concerns and experiences during last three dental visits (Section 2, Q1, Q2, and Q3 combined). Outcome 3: overall concern about safety at the dental office (Section 2, Q8). Outcome 4: overall perceptions that patients shoud report safety concerns or experiences to dental providers and staff (Section 2, Q9). a
Statistical significance (P value , .05) based on generalized linear models (GLM) with robust variance estimates (Poisson family).
DISCUSSION 25,26
It is no secret that AEs occur in health care, and the recent statistics emerging from dentistry confirm this observation.22,27–32 This study addresses a gap in the literature regarding dental patients’ perceptions about safety at the dental clinic and their reporting of safety concerns and/or experiences. Our findings suggest that dental patients can be a valuable source of information about the safety of our dental clinics; however, their level of engagement to promote safety is not currently optimal. Patients reported various reasons for not sharing their past AE experiences and safety concerns with the dental staff and care providers, including a fear of being perceived as difficult patients or retribution when seeking future dental care, which underscores the need for more research with dental patients to fully understand the basis for these fears and to develop strategies for overcoming them. This absence of a feedback loop between the dental clinic and dental patient has limited our ability to learn from past mistakes and to identify potential hazards or threats to safety. For example, only one patient made a formal complaint but never received any follow-up. Patients need to trust that we will take their concerns seriously and take steps to effectively address those concerns. Furthermore, dental clinics need to proactively solicit patient feedback about their safety concerns and experiences rather than reacting to patient-initiated complaints to become true learning health systems.33 With advancements in technology and the avalanche of personal devices, opportunities now exist to engage dental patients directly and in more meaningful ways.34–36 Patients already use generic online community platforms such as
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Yelp, Zocdoc, and Google to read and/or post reviews about their health-care providers and experiences with the health-care system, albeit in an unstructured manner.37–39 These reviews also tend to focus on the extremes of experiences, that is, exceptional or very poor-quality dental care, and may not contain enough useful information to enable learning.38 Some researchers have sought to harness this “wisdom of the crowd” potential through platforms such as HealthTalkOnline.org, which synthesizes patients’ everyday experiences into searchable topics that enable learning.40,41 Dental professionals can also tap into the wisdom of their patients by developing these types of online platforms for sharing of safety experiences and concerns in a standardized manner. This guided use of social media can potentially enhance learning for qualityimprovement purposes. Indeed, researchers have analyzed data from social media and online platforms to improve trust in dental provider rankings/matching with patients,42–44 to understand gaps in patient knowledge as well as their use for peer support or learning about dental diseases,45 and to explain patient behaviors related to dental conditions.46 Rather than responding defensively to patients’ use of social media and online platforms, care providers could work collaboratively with patients to identify credible internet-based sources of health information and develop tools for filtering their content.47 A variety of Web-based reporting systems have been used successfully by our medical colleagues to capture information about errors and AEs.48–51 While most of these reporting systems have been targeted toward care providers and staff, a few have sought to capture patient reports as well.52–54 For example, a study of patient reports
The Journal of EVIDENCE-BASED DENTAL PRACTICE
to the United Kingdom’s Yellow Card Scheme revealed that patients provided more detailed descriptions of their adverse drug reactions than health-care providers and often provided pertinent details regarding the causes and impact of these adverse drug reactions on their lives.55 These patient reports often led to improved pharmacovigilance by enhancing signal generation and detection.55 Dentistry can learn from the successes (and challenges) of these patient-based incident-reporting systems as we seek to develop our system and/or modify existing systems such as the Dental Patient Safety Foundation’s Web-based incident-reporting system (https:// www.dentalpatientsafety.org/) for care providers. Ideally, a user-friendly, and cross-platform, that is, mobile and desktop system, which provides periodic reports on submitted events, will offer the greatest utility for patient engagement and care provider learning. As observed in our study, some factors that affected the reporting of past safety experiences and concerns included the fear of being perceived as difficult patients and the severity of the incident. Patients have been shown to generally abstain from being confrontational about safety and often prefer to ask factual questions rather than challenging ones.56 Unplanned financial costs, unplanned visits, and the impact on their quality of life were other significant factors noted as potentially influencing patient reporting to dental providers and staff in the future. Although dental patients were not more prone to sharing their past safety concerns and experiences with dentists compared with other clinic staff, one out of every ten patients (11.8%) reported that they would be more likely to share their safety concerns or experiences if their care provider asks them about it, which aligns with observations by Davis et al. that showed the willingness of patients to participate in safety increased with provider encouragement.56 The relationship between race and patient safety has been relatively underexplored and mixed because of minority populations being underrepresented in most safety studies.57 Owing to the limited number of observations, the finding that persons belonging to the “AI/AN/NH/ OPI” racial category had a higher probability of having a past safety concern or experience than the “white” racial category, while other racial groups had lower probabilities, warrants further exploration in future research studies with larger sample sizes. Overall, patients were generally supportive of the concept of reporting safety experiences and concerns irrespective of their past actions. This aligns with findings by our medical colleagues.58–61 However, they need to be educated about their roles, empowered to speak up through direct encouragement by care providers/clinic staff, and engaged in a meaningful manner; for example, through the use of health information technology.34–36 Conversely, although Davis
et al. found that being female, younger, and more educated increased the willingness to be engaged in safety-related activities,61 this was not observed in our study sample. Instead being female and more educated were associated with a reduced overall perception that patients should report safety concerns and experiences to dental care providers and staff. One explanation for this observation in our study population might be their empathy for the nature of a training environment and a disposition toward protecting their student care providers from the negative consequences associated with a patient complaint. Furthermore, self-reported poor oral health status was significantly associated with a lower predisposition toward patient reporting of safety incidents to care providers, which aligns with findings from our previous study in South Africa that found a significant association between having a past dental AE experience and dissatisfaction with oral health status.22 The finding that Spanish-speaking patients were significantly more likely to have an overall perception that patients should report safety concerns and experiences to dental care providers and staff was unexpected and deserves further exploration because this has not been previously documented, and the Latino population has been relatively underrepresented in most patient safety studies.57 This study assessed the past experiences and reporting of safety incidents by dental patients, their perceptions toward future reporting, and role as potential partners in promoting safety. It provides a baseline that establishes the magnitude of the problem from the patients’ perspective and informs the design of future research studies that will seek to better engage patients in safety reporting to determine the incidence of dental AEs and their related events. Our study has several limitations. First, the use of a survey approach may have limited our ability to capture the subtle nuances and to gain a comprehensive understanding of the reasons behind past behaviors by dental patients. Qualitative studies were also conducted concurrently to provide patients with some more opportunity to expand upon their past safety concerns and experiences, and those results are discussed elsewhere. Second, although participants represented a diverse pool of patients, participants were limited to a single site which limits the generalizability of our study findings. Third, only nonemergency patients were included, which might have systematically excluded a cohort of patients that were more likely to experience AEs. Finally, none of the patient reports were validated with their care providers or dental records. Although, given the limited number of patients who shared these experiences with the clinic staff or care providers, it would be reasonable to assume a low concordance between both sources of data, hence underscoring the need to capture the patient’s experiences directly from the patients.
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CONCLUSION Most dental patients are concerned about safety at the dental clinic, and although only a third of them shared their past concerns or experiences with their dental care providers or clinic staff, most patients believe that patients should report these concerns and experiences to the clinic staff. Being female, highly educated, and having poor oral health were associated with a decreased overall perception that patients should report safety concerns and experiences to dental care providers and staff.
ACKNOWLEDGMENT Author contributions: E.O.-U. contributed to conceptualization, funding acquisition, methodology, project administration, resources, supervision, validation, and visualization. S.P. performed data curation. S.P. and A.-I.Y. performed a formal analysis. E.O.-U. and S.P. prepared the original draft. S.P. and A.-I.Y. chose the software programs used in the study. A.N. and J.P. contributed to investigations carried out in the study. All authors contributed to reviewing and editing the article.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi.org/10.1016/j.jebdp.2020.101424.
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