The oft quoted phrase ‘To err is human‘ originates from the English writer Alexander Pope’s (1688-1744) poem An essay on criticism. However, this idea or concept that mortals are liable to make mistakes was acknowledged as far back as Roman times when Cicero (106-43BC), the great statesman and orator, opined that “Any man can make mistakes, but only an idiot persists in his error.” 

Incidence of adverse outcomes in healthcare 

Given the fact that humans are fallible, and error is normal, it will come as no surprise that things can and often do go wrong within the world of healthcare – what are variously called patient safety incidents, adverse events, or adverse outcomes. The data would suggest that up to 2% of patients undergoing medical GP consultations1 and 10% of patients in hospitals2 have an adverse outcome, with approximately 50% of these being preventable. Although there is less research, it is highly likely that adverse events and outcomes in dentistry occur frequently as they do in medicine. A study of 1,465 severe incident reports from primary care dentistry in England and Wales identified that 23.6% of errors related to delays in treatment, 15.6% were procedural errors (including wrong tooth extraction) and 11.1% were medication related incidents.3 

Precursors to error 

It is only natural to focus on the adverse outcome itself, but arguably, what is equally if not more important is trying to understand what led up to the error. Such insight can, not only, potentially help the individual clinician avoid a similar issue arising again, but more broadly can enable the profession to address any recurrent themes. So, before considering practical strategies to try and prevent or mitigate errors from happening in dentistry, it is important to understand why, or under what conditions, people make mistakes. An industry keen to understand the answer to this question was aviation, and they have identified 12 key elements that are proven to influence people into making mistakes.4 The so called ‘Dirty Dozen’ is a concept that was developed by Gordon Dupont, in 1993, while he was working for Transport Canada, and formed part of an elementary training programme for Human Performance in Maintenance. Listed in no specific order below, at first blush it is easy to see how each of these factors could contribute to human errors individually, and how in combination they could act to amplify the risk. Let us now briefly look at each of these factors in turn, and how they might relate to the world of dentistry. 

The dirty dozen 

1. Lack of communication or communication issues are often uncovered when a root cause analysis is carried out after an adverse outcome in dentistry. A practical example might be a wrong tooth extraction as part of an orthodontic treatment plan, where a misunderstanding arose between two practitioners as to which tooth or teeth were to be removed. Failures in communication can also arise between practitioners and patients, and/or practitioners and staff members. It is often quoted that only 30% of verbal communication is received and understood. We tend to remember the start and end of conversations. Therefore, if we have an important message to convey, consider saying this at the start and then repeating it at the end of a conversation, and (depending on circumstances), also consider following up in writing. 
2. Distraction could be from our core role, which may be related to factors inside or outside our workplace, or simply due to tiredness.Many practitioners will be familiar with the scenario in a busy dental clinic whereby a colleague or support staff member seeks your attention. Where possible, however, look at how you can manage distractions. For instance only urgent messages should be communicated while treating patients. If you must stop a procedure, then it can be helpful to retrace the first steps again to ensure nothing is missed. 
3. Lack of resources couldinclude staff, equipment, or materials. It is easy to imagine clinical scenarios whereby understaffing, or not having the appropriate material/equipment to carry out a clinical procedure has ultimately contributed to an adverse outcome. It is prudent, therefore, to have processes in place to establish that you have the necessary resources (such as stock checks, staff cover for illness, leave and so on).
4. Stress in all its many manifestations, and with its far-reaching effects,is never easy to avoid in our busy working lives. The ability to recognise the signs and symptoms of stress, along with its proactive management, is therefore very important. External pressures can sometimes affect our decision-making process, and when we are aware that this is occurring, it can be helpful to share your decision with colleagues or the wider team. It can also be helpful to take regular short breaks or step back from the procedure to take stock. Also remember to look for signs of stress in others.
5. Complacency can occurthrough over-familiarity, lack of respect for the process, or simple boredom. Overconfidence can arise from repeating the same task numerous times. Clinical procedures that become routine and repetitive can leave us automatically assuming the same outcome will occur. We do not expect anything untoward to happen and we can drop into a comfort zone. We can try and avoid this by looking for errors, using checklists and learning from the experience of others. Similarly, we can help others by sharing knowledge of events or procedures which did not go according to plan. 
6. Lack of teamwork can occur for many reasons including steep practice hierarchies, disempowerment of certain staff members, working with different colleagues, or even new members of the team feeling isolated or having had a lack of induction. The importance of working as a team cannot be overstated and for those procedures that carry a higher risk, we should consider using the team to double check, for instance, that we are putting the forceps on the correct side and on the correct tooth. If we have a protocol, then be guided through the process by team members.
7. Pressure workplace-related pressures can impact on our risk of making a mistake. These pressures may be real or perceived. We should never be afraid to communicate our concerns to others or ask other team members for help. Having protocols in place to manage some of the common scenarios, may allow the wider team to deal with these situations independently, thereby removing the pressure from those dealing with the clinical situation. Being aware of the patient’s safety is paramount.
8. Lack of awareness of what we are trying to achieve orperhaps of how our behaviour and actions could be impacting on others. This could include a failure to recognise a change in the situation or the possible consequences of our actions. Another benefit of working as a team is that it can help ensure that everyone is aware of each other’s normal behaviours and when they might be needing help.
9. Lack of knowledge perhaps we don’t know enough to do the job well, or we don’t have a full and thorough understanding of the regulations and processes that we are required to follow to ensure patient safety. It is important, therefore, to learn to say ‘no’ and not to feel pressured into doing something that we may not have the skill or competency to do. To quote the Chinese philosopher Confucius: “Real knowledge is to know the extent of one’s ignorance.” We must also appreciate that if we only learn once, our knowledge is limited to that available at the time. Consequently, we should continually update our thinking with Continuing Professional Development (CPD), and activities such as peer review to reduce the chance of being unaware of what we don’t know.
10. Fatigue impacts on cognition and behaviour and,consequently, it increases our risk of making mistakes. Road safety research tells us that ‘being awake for 17 hours has the same effect on your driving ability as a BAC (blood alcohol concentration) of 0.05%. Going without sleep for 24 hours has the same effect as a BAC of 0.1%”.5 It is not a big leap to appreciate how fatigue is also likely to affect our dentistry. It is difficult to complete a day’s work with intense concentration without some form of fatigue becoming evident. It can be useful, therefore, to consider planning your day to allow complex and cognitively demanding procedures to be scheduled at a time when you are least likely to be fatigued. Also consider taking regular short breaks and remember that fatigue can affect any member of the team, so watch out for it in others as well as yourself. 
11. Lack of assertiveness can arisefrom the perception that if you say something, you could look foolish or be ignored. In a good team environment, everyone should be able to openly discuss concerns, while at the same time offering positive solutions. If we cannot speak up for safety, both by setting safe boundaries for our practice, and raising concerns with a colleague about their intended practice, then we cannot truly ensure patient safety. 
12. Norms are excepted, yet unwritten, rules of behaviour. Many norms can be helpful, but just because something is always carried out a certain way doesn’t mean that it is correct. Normalisation of sub-par performance or behaviour has been referred to as ‘ethical fade’. It is important, therefore, to follow the correct procedure, and not just that which we are used to. It can be useful to use team meetings to discuss what is always done and whether that is still in line with current teaching. 

References 

1 Gaal et al. 2011 

2 Lessing et al. 2010; De Vries et al. 2008 

3 Patient Safety Incidents in Primary Care Dentistry in England and Wales: A Mixed-Methods Study - PubMed 

4 https://www.skybrary.aero/index.php/The_Human_Factors_%22Dirty_Dozen%22 

5 http://www.tac.vic.gov.au/road-safety/safe-driving/tips-and-tools/fighting-fatigue