Improving patient safety through a clinical audit spiral: prevention of wrong tooth extraction in orthodontics.

Introduction With an increasing demand to improve patient safety within the NHS, it is important to ensure that measures are undertaken to continually improve patient care. Wrong site surgery has been defined as a 'never event'. This article highlights the importance of preventing wrong tooth extraction within orthodontics through an audit spiral over five years investigating the accuracy and clarity of orthodontic extraction letters at the University Dental Hospital of Manchester.Aims To examine compliance with the standards for accuracy and clarity of extraction letters and the incidence of wrong tooth extractions, and to increase awareness of the errors that can occur with extraction letters and of the current guidelines.Method A retrospective audit was conducted examining extraction letters sent to clinicians outside the department.Results It can be seen there has been no occurrence of a wrong site tooth extraction. The initial audit highlighted issues in conformity, with it falling below expected standards. Cycle two generally demonstrated a further reduction in compliance. Cycle three appeared to result in an increase in levels of compliance. Cycles 4 and 5 have demonstrated gradual improvements. However, it is noteworthy that in all cycles the audit standards were still not achieved, with the exception of no incidences of the incorrect tooth being extracted.Conclusion This audit spiral demonstrates the importance of long term re-audit to aim to achieve excellence in clinical care. There has been a gradual increase in standards through each audit.

Evaluation of the end user (dentist) experience of undertaking clinical audit in the post April 2001 general dental services (GDS) scheme.

INTRODUCTION: A mandatory scheme for clinical audit in the general dental services (GDS) was launched in April 2001. No evaluation of this mandatory scheme exists in the literature. This study provides an evaluation of this scheme. More recently a new dental contract was introduced in the general dental services (GDS) in April 2006. Responsibility for clinical audit activities was devolved to primary care trusts (PCTs) as part of their clinical governance remit. METHODS: All GDPs within Essex were contacted by letter and invited to participate in the research. A qualitative research method was selected for this evaluation, utilising audio-taped semi-structured research interviews with eight general dental practitioners (GDPs) who had taken part in the GDS clinical audit scheme and who fitted the sampling criteria and strategy. The evaluation focused on dentists' experiences of the scheme. RESULTS: The main findings from the analysis of the GDS scheme data suggest that there is clear evidence of change following audit activities occurring within practices and for the benefit of patients. However, often it is the dentist only that undertakes a clinical audit project rather than the dental team, there is a lack of dissemination of project findings beyond the individual participating practices, very little useful feedback provided to participants who have completed a project and very limited use of formal re-auditing of a particular topic. CONCLUSIONS: This study provides evaluation of the GDS clinical audit scheme. Organisations who propose to undertake clinical audit activities in conjunction with dentistry in the future may benefit from incorporating and/or developing some findings from this evaluation into their project design and avoiding others.

A health equity methodology for auditing oral health and NHS General Dental Services in Sheffield, England.

OBJECTIVES: To describe a method used in a health equity audit (HEA) of oral health and National Health Service (NHS) General Dental Services. METHODS: Need, demand and provision of NHS General Dental Services were estimated by electoral ward using readily available data. Need was estimated using five-year-old dmft data. Scheduled and unscheduled demand were differentiated; scheduled demand was estimated using NHS dental registration data and unscheduled demand using emergency clinic and NHS Direct call activity data. Provision was estimated using self-declared dentist NHS hours and NHS Units of Dental Activity practice allocations. All variables were correlated with socioeconomic deprivation in each electoral ward, estimated by rates of receipt of Income Support. SETTING: Sheffield, England. RESULTS: Estimated need in electoral wards varied and correlated positively with increasing socio-economic deprivation. Scheduled demand tended to be lower and unscheduled demand higher in more deprived wards. Estimates of NHS General Dental Service provision indicated marginally higher provision in more deprived wards, though the correlation was weak. A synthesis of the findings estimated where need was least well met by provision. CONCLUSION: A HEA of oral health and NHS General Dental Services can be undertaken using readily available data. However, data used to estimate need, demand or provision may have to change for future audits as the data routinely collected changes.

A prospective audit to investigate the level of consciousness of children requiring conscious sedation using an 'alternative technique'.

The aim of this prospective pragmatic audit was to investigate the level of consciousness experienced by children requiring conscious sedation in a primary care sedation service, using an 'alternative technique' to avoid referral to hospital for general anaesthesia. This technique was only applied to children who were unable to accept treatment with the use of standard inhalation sedation. The technique involved titrated inhaled oxygen and nitrous oxide and titrated sevoflurane with intravenous fentanyl and titrated midazolam. The described technique was provided by an experienced team with appropriate facilities that complied with contemporary standards and guidance. During treatment and recovery the consciousness level of children was recorded using a modified Wilson's scale. Of the sample of 573 children who received the audited technique, 1.9% (11 children) scored level 5 on the modified Wilson scale (eyes closed but responsive to mild physical stimulus). Due to the fine control this technique offers, the duration of this level of consciousness was for mostly less than a minute and no more than five minutes. No children became unresponsive. The results of this audit demonstrate that the technique meets current standards and guidelines for 'alternative' conscious sedation, with a wide margin of safety and the rendering of loss of consciousness unlikely. 99% of patients who would otherwise have required general anaesthetic for dental treatment successfully completed their treatment using this technique.

Audit of dental reports (II): First Phase-II study in a Spanish Faculty of Dentistry

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As a measure for correction of deficiencies registered through an audit of dental records in the ComprehensiveDentistry Clinic of the Dentistry Faculty of the University of Seville, we elaborated a new format for dental records which was used in 70 patients, carrying out a monitoring audit (Phase V) by applying the same quality criteria and criteria for data collection used in the initial audit (Phase III). We calculated the indices of fulfilment of 46 quality criteria, extending fulfilment percentage to 41 criteria, while statistically significant differences were found in 25criteria. The standard prefixed as appropriate (75 %) was reached in 29 criteria (against the 12 criteria in which such standard was reached in the first dental audit).It is essential that faculties of dentistry develop systems for dental record revision which may help students achieve the competence of registering dental-care steps appropriately, teachers identify and give response to educational problems, and clinic administration prevent and correct conflicts, at the same time that they all ensure quality in serviceprovision, ease relations with customers and protect users against legal vulnerability

Dental audit (I): Exact criteria of dental records; Results of a Phase-III study

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Objective: Evaluating the quality of dental records in the Faculty of Dentistry of the University of Seville (Spain). We attempted to collect and/or develop identifiable elements of dental care used to evaluate its appropriateness, as well as to measure its level of filling-in between 1999 and 2004 (Phase III of the record audit).Method: The 46 criteria used to evaluate dental care are shown, measuring —in 50 dental records randomly chosenwithin a 5-year-time period— their level of filling-in (Phase III of a health audit).Results: A low level of filling-in was observed in all quality criteria defined. No record was found to be free from errors. A maximum of 36 criteria out of 46 was fulfilled (mean of 20.8).Conclusions: The standard of appropriate filling-in was only met in 12 criteria (75 %), the results being poor, due to the importance which clearly deficient aspects related to diagnosis and treatment plan have in the process of patient care. For such reason, we suggest a remedial action (Phase IV) developing a new model of dental record and its subsequent re-evaluation (Phase V), which will be subject to analysis in the second part of this paper

The impact of clinical audit on antibiotic prescribing in general dental practice.

OBJECTIVE: To reduce the number of antibiotics inappropriately prescribed by general dental practitioners, and to increase overall prescription accuracy. DESIGN: A prospective clinical audit carried out between September and March of 2002-3 and 2003-4. SETTING: General dental practices in Eastern England. SUBJECTS AND METHODS: The pre-audit antibiotic prescribing practices of 212 general dental practitioners were recorded over an initial six week period. On each occasion this included which antibiotic had been chosen, together with its dose, frequency and duration, as well as the clinical condition and reason for which the prescription had been raised. When related to prophylaxis, the patient's medical history was also noted. Following education on contemporary prescribing guidelines, presentations which illustrated the practitioners' previous errors, and the agreement of standards to be achieved, the process was repeated for another six weeks, and the results compared. RESULTS: In the pre-audit period, 2,951 antibiotic prescriptions were issued, and during the audit this was reduced by 43.6% to 1,665. The majority were for therapeutic reasons, with only 10.5% and 13.6% for medical prophylaxis during the pre-audit and audit periods respectively. Over both periods, amoxicillin and metronidazole were the two most commonly prescribed antimicrobials (63.4% and 21.2% respectively). In the pre-audit period, only 43% of all prescriptions were error free in dose, frequency, and/or duration of use, but this rose significantly to 78% during the audit. Equally, using contemporary published guidelines, out of all the prescriptions made in the pre-audit period, only 29.2% were deemed to be justified, as compared to 48.5% during the audit. CONCLUSIONS: Clinical audit, in conjunction with education, and prescribing guidelines can favourably change antibiotic prescribing patterns among general dental practitioners.

The cleft audit protocol for speech-augmented: A validated and reliable measure for auditing cleft speech.

OBJECTIVES: To develop an assessment tool for use in intercenter audit studies of cleft speech and to test its acceptability, validity, and reliability. The tool is to be used systematically to record and report speech outcomes, providing an indication of treatment needs and continuing burden of care. SETTING: Regional Cleft Center, U.K. METHODS: The Cleft Audit Protocol for Speech-Augmented (CAPS-A) was developed by three cleft speech experts who identified the key features required from existing assessment measures. Criterion validity was assessed by comparing the Cleft Audit Protocol for Speech-Augmented outcomes reported for 20 cases with clinical assessment results and other investigations. Intra- and interrater reliability were tested following the training of specialist speech and language therapists who used the Cleft Audit Protocol for Speech-Augmented on two occasions to assess 10 cases. The raters evaluated acceptability and ease of using a questionnaire. RESULTS: The mean percentage agreement for criterion validity in each section was 87% (range 70% to 100%). Both intra- and interexaminer reliability were rated as good/very good (Kappa 0.61 to 1.00) for seven sections and moderate (Kappa 0.41 to 0.60) for three sections. Raters reported that the Cleft Audit Protocol for Speech-Augmented was acceptable and easy to use with appropriate training. CONCLUSION: An acceptable, valid, and reliable cleft speech audit tool has been developed based on a small sample. The Cleft Audit Protocol for Speech-Augmented is recommended for use in intercenter audit studies in the U.K. and Ireland and could be used in other English-speaking countries. In addition, it has wider applicability for use in reporting speech outcomes of surgical procedures.

An audit of the standard of response letters sent by hospital specialists to general dental practitioners following a referred patient's first appointment.

INTRODUCTION: To assess the standard of response letters issued by dental hospital departments according to the requirements of the recipient dentists. PATIENTS AND METHODS: A cross-sectional survey from a UK dental hospital. All response letters issued from hospital departments between 1 January and 1 March 2003 were copied. Fifteen letters were selected for each department on a chronological sampling frame. The hospital response letters were compared to dentists' requirements, as determined in a previous study. RESULTS: Almost all departments achieved a minimum total score of 80%. The scores across all of the departments together achieved over 90% for all items of information except those relating to time. The samples of the three departments to score over 90% were the only ones to include SHO letters. The sample of the department with the highest score contained the most SHO letters and no consultant letters. CONCLUSIONS: The content standard of response letters was consistently high, particularly those letters written by SHOs, and most were written within 18 days of the patient's appointment. The use of a previously conducted questionnaire survey of dentists' opinions provided a valid means of assessing the quality of the response letters from hospital specialists.

Making the most of audit.

This article explores the steps in making the most of audits conducted in primary dental care. Audit is the principle method of measuring consistency in quality assurance systems and so is an essential part of clinical governance.

Clinical audit: introduction: getting started.

Clinical audit can benefit your practice and your patients. It is one of the pillars of clinical governance that will ensure that SAAD members deliver the best quality dental care. If you have experience of clinical audit that you would like to share with members, we would like to hear about it, so other members can learn from your experience.

Clinical outcome monitoring program (COMP): a new application for use in orthodontic audits and research.

Awareness has been growing in recent years about the importance of clinical auditing to provide better orthodontic care to patients. A new, flexible software package, Clinical outcomes monitoring program (COMP), designed to facilitate clinical audits and research, is described. COMP is simple and easy to use and allows clinicians to gather a full data set with the PAR, ICON, or IOTN indexes and to accurately describe clinical outcome and activity. An audit was carried out to demonstrate the use of the software. A total of 205 consecutively finished patients from Good Hope Hospital, Sutton Coldfield, United Kingdom, were analyzed with the software. General and personal trends for 2 clinicians working in a multioperator unit were examined. Results for the unit showed an average PAR improvement of 77.5%, with clinician A performing marginally better overall than clinician B. A general tendency to be less efficient at improving the right, rather than the left, molar relationship was identified. This problem was particularly evident for clinician B, who achieved on average only a 10% improvement in this area. We conclude that COMP is potentially a useful and powerful tool to facilitate orthodontic audits and research.

An orthodontic patient administration system (OPAS) for complete departmental management.

There is a requirement for effective management and audit in today's hospital environment. This paper discusses some of the principal requirements of a computer program for comprehensive orthodontic department management and describes in detail one system.

Anales del primer Congreso Internacional de Auditoría Odontológica

Acto inaugural. Vigilancia epidemiológica como recurso de auditoría para determinar prioridades en salud. Matriculación, certificación y recertificación. Quién la genera y quien la otorga?. Políticas de salud en el Siglo XXI. Mercantilización de la salud. Es auditoría la de hoy? Gestión y ética en las políticas de los servicios de salud. El mercado y su influencia en la atención odontológica. Capacitación de los auditores y quienes los forman