tooth extractions, eight cases relating to endodontic therapy (including fractured instruments, perforations, and leakage of sodium hypochlorite into the apical tissues) and two cases of crowns being swallowed by patients. The three “near misses” were all in relation to radiographs not being taken prior to third molar extractions. Obadan and colleagues (2015) performed a retrospective review of dental adverse events reported in the literature. Databases were searched and data were extracted on background characteristics, incident description, case characteristics, clinic setting where the adverse event originated, phase of patient care when the adverse event was detected, proximal cause, type of patient harm, High-risk populations Although the safety of all patients is of primary concern to healthcare professionals, some patients presenting special concerns include: ● Infants and children. ● Older adults. ● Pregnant or breastfeeding patients. ● Patients in intensive care units. ● Persons of limited language skills or limited literacy. ● Patients with impaired renal function, liver function, or immune systems. It is important that healthcare providers recognize the special needs of vulnerable patients. Infants and children The most common anesthesia used in children’s dental care is local anesthesia. Complications from dental anesthesia for children are a major area of concern for practitioners. True anesthetic allergies are rare, but complications are common. Diligent monitoring of the child and staff training in advanced life support techniques are essential for successful anesthesia use in children. With proper airway management and ventilation, an anesthetic-induced seizure resulting from a local anesthetic overdose often ceases in less than one minute (Malamed, 2003). Dental practitioners must carefully review a patient’s health status and other conditions that may cause adverse effects. An adverse drug reaction is most likely to occur during the injection or within 5 to 10 minutes (American Academy of Pediatric Dentistry, 2009). Calculate the local anesthetic dose for each patient, based primarily upon his or her weight (mg drug/kg body weight) and physical status (Weaver, 2007). Base dosage on ideal body weight rather than actual weight for patients who are obese. Young children with low body weight are at higher risk for receiving relatively large amounts of local anesthetic (Chin, Yagiela, Quinn, Henderson, & Duperon, 2003). Toxic levels of local anesthetic are reached quickly in children. Overdose of local anesthetic can occur if blood pressure elevates and affects the central nervous system. The child can become unconscious or experience complete respiratory failure. Local anesthetic toxicity is exceptionally rare in infants and children; however, dysrhythmias, cardiovascular collapse, seizures, and transient neuropathic symptoms have been reported (Ecoffey, 2005). True allergies to local anesthetics occur in fewer than 1% of cases (Bahl, 2004). The bones in a child’s head and neck are less dense than are those in adults, increasing the risk with local anesthesia, which will be absorbed and dispersed more quickly. Both local effects and systemic effects can be seen in complications of local anesthetic administration (Chiu, Lin, Hsia, Lai, & Wong, 2004). Local effects may include but are not limited to spread of infection, hematoma, nerve damage, or blocking of the facial nerve. Infections, risk of bacterial heart infection, cardiovascular problems, liver disease, and other complications can be seen in systemic effects (Chin et
degree of harm, and recovery actions. The review identified approximately 182 publications (270 cases). Delayed and unnecessary treatment/disease progression after misdiagnosis was the largest type of harm reported. Of the reviewed cases, 24.4% reported permanent harm to the patients; death of the affected patient was reported in one of every ten adverse event case reports reviewed. These case reports provided a window into understanding the nature and extent of dental adverse events, but for as much as the findings revealed about adverse events, they also identified the need for more broad- based contributions to the collective body of knowledge about adverse events in the dental office and their causes.
HIGH-RISK POPULATIONS AND PATIENT EDUCATION
al., 2003). Success of dental anesthesia procedures depends on proper monitoring of the patient and giving clear, concise postoperative instructions to the parents or guardians. Because children’s dosages are dependent upon age, weight, and other factors, dental practitioners should create a chart showing the maximum number of carpules of various local anesthetics to be used for various body weights. Charts should be posted in every operatory of the dental office. Remaining current in specialized training and continuing education is also extremely important to the success of the dental practice and the health of its patients (Malamed, 2003). Careful monitoring of the child’s medical and dental histories is important. Close monitoring of the child’s vital signs and respiration during treatment is essential, and staff members who monitor patients must have advanced training. In several adverse incidents, the dental assistant was inadequately trained in the proper monitoring of the patient and the appropriate protocol for emergency medical treatment (Weaver, 2007). Staff must be knowledgeable and prepared for dental and medical emergencies. Additionally, because many medications employed in pediatrics are used “off label” (utilized for purposes other than their intended action), they have never been trialed in that population. This means that the best dose is unknown, and there is potentially a much narrower therapeutic index (margin of safe dosage). The medications that are available in pediatric-specific forms also have varying doses. For example, acetaminophen comes in children’s formulation (160 mg/5 mL) and infants’ formulation (160 mg/1.6 mL). The larger percentage of liquid oral medications in pediatric settings increases the risk of a preventable adverse event, such as accidental intravenous administration. Pediatric medications also cover a broad range of weights, from the tiniest baby in the neonatal intensive care unit to 17- and 18-year-olds. Combine this with the complexity of calculations that may be required and it becomes easy to misplace or not see a decimal point. When errors do occur, pediatric patients are less likely to be able to tolerate them because their organs are immature and they metabolize drugs very differently from adults. Additionally, children often do not have the communication skills to alert clinicians to potential drug errors or adverse effects (TJC, 2008). The practitioner needs to enlist the help of parents and guardians in protecting children in clinical situations. As outlined in Table 3, parents and families can help reduce the likelihood of adverse events by being fully informed and asking questions about their child’s care. Older adults The aging process imposes several threats to older adults in the healthcare system. Vision and hearing may be diminished, and cognitive abilities may be impaired to varying degrees. These problems contribute to difficulty in communicating among patients and caregivers. Illnesses that require hospitalization
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Book Code: DFL3024
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