Julian Perez, J.D., Chief Legal Officer, dentalcorp; Kristy Pilatzke, Risk and Compliance Officer, dentalcorp
Imagine the following scenario: A temporary dental assistant loads a sterilizer before lunch, and despite pressing the start button, the sterilizer fails to begin the reprocessing cycle. Another assistant returns later to unload the pouches. In a rush because one of their appointments ran long, they fail to confirm the status of the indicators, incorrectly marking the instruments as passed (i.e. sterilized), and subsequently store and distribute the instruments. Fortunately, another assistant notices the failed indicators. The load is documented as failed and all instruments are collected PRIOR to being used on any patients. It is then repacked and run through the sterilizer. The two assistants breathe a sigh of relief as there was no harm done to the patients. In the hustle and bustle of the busy dental centre, the incident is forgotten; business continues as usual.
Amongst healthcare risk management and safety professionals, such close calls go by the name of ‘near misses’[1] and they happen in dental offices every day. Because no harm results, ‘near misses’ are often forgotten or even pushed aside. This is a mistake. What busy oral healthcare workers can overlook is that ‘near misses’ provide a signal that things aren’t working as intended. A ‘near miss’ is like that dashboard warning light you don’t quite understand. If you ignore it long enough, something harmful will happen. According to Occupational Safety Group Inc., a company specializing in workplace safety, a ‘near miss’ indicates that an uncontrolled hazard exists, and while an incident did not occur this time, one may the next time unless some type of control is put in place.”[2]
Conversely, to organizations possessing strong safety cultures, ‘near misses’ represent a limitless, and invaluable source of learning opportunities. Without harm, team members feel free to report what they’ve seen as they are less likely to experience "fear of blame"— the largest barrier to incident reporting in healthcare. To safety experts, a ‘near miss’ is a gold nugget – hard to find but extremely valuable. Safety experts estimate that each clinical staff member is aware of no fewer than three ‘near misses’ every year. As a people manager, healthcare professional, or leader, it’s important to utilize this precious resource.
So how does one encourage ‘near miss’ reporting when this has not been a custom within the clinic? Launch a “Good Catch” campaign, i.e., an incentive-based program designed to foster a growing culture of safety by recognizing and celebrating the reporting of risks before harm occurs.
Foster the safety culture in your practice by creating a robust ‘near miss’ program:
- Establish a Reporting System
In a busy practice, a system must be accessible and allow for workers to quickly complete an incident report. Aim to capture the ‘what’ and ‘how’ in an electronic system. Reporting a ‘near miss’ shouldn’t take more than three minutes or your busy team members simply won’t do it. dentalcorp’s incident reporting platform, dc safety, allows team members to report safety incidents, property damage, cyber security breaches, and of course, ‘near misses’. - Foster trust
Ensure that your clinic becomes and remains a supportive, transparent, and non-punitive workplace. Your team will voluntarily bring safety issues forward only if there is a psychologically safe environment where workers feel empowered to speak up. This can be supplemented by providing workers with a channel to report concerns anonymously. dentalcorp uses EthicsPoint for those who may feel more comfortable anonymously reporting an incident. - Provide Training
Workers need to be able to identify and recognize potential hazards. This can be further developed through sharing details of reported events including lessons learned to benefit both patients and practitioners in dentistry. - Incentivize
Celebrate safety. Good catch campaigns are ways to increase the frequency and quality of ‘near miss’ reporting. The Health Insurance Reciprocal of Canada, like many sophisticated health care organizations, believes that Good Catch Awards and acknowledging individuals with safety spotlights are critical to “continuously building on [their] safety-first culture." - Embrace your role as a leader
Leaders are key in creating a workplace culture that facilitates effective incident reporting. According to the Health Services Centre of the Canadian Armed Forces, “the surest way to learn from mistakes and mitigate against them is to create an environment where we can acknowledge errors and act to correct what underpins them.”[3] Then, once an incident or ‘near miss’ has been reported, leaders must act to address concerns. Workers need to feel like something is done in response to their reports otherwise, they will stop. As a leader, it's important to maintain a constant healthy feedback loop demonstrating the value of an incident reporting system.
Originally published in Oral Health journal.
References
[1] Canadian Patient Safety Institute | Home / Tools & Resources / Patient Safety and Incident Management Toolkit / Glossary: https://www.patientsafetyinstitute.ca/en/toolsResources/PatientSafetyIncidentManagementToolkit/pages/glossary.aspx, last accessed on April 26, 2022.
[2] Near Miss Accidents in the Workplace: How to Turn Them Into Learning Opportunities, https://osg.ca/workplace-near-miss-accidents/#:~:text=Why%20are%20near%20misses%20important,control%20is%20put%20in%20place, last accessed April 26, 2022.
[3] Patient Safety, https://www.canada.ca/en/department-national-defence/services/bases-support-units/cf-health-services-centre-ottawa/patient-safety.html, last accessed on April 26, 2022
About the Authors
Julian oversees dentalcorp’s legal, regulatory compliance, and enterprise risk management functions. He is also accountable for the organization’s entire legal function, including litigation, employment relations, mergers and acquisitions, and commercial and corporate governance. A graduate of Yale University and Columbia Law School, he commenced his legal career as an attorney at a leading international law firm. Before joining dentalcorp, he oversaw a variety of functions with Canada’s largest dental regulator, including dental malpractice defense, misconduct complaints, and investigations.
Kristy Pilatzke is an experienced quality, risk and compliance professional with over 14 years of experience in regulated healthcare industries, from pharmaceuticals manufacturing and specialty pharmacy to acute care and dentistry. She is currently a Risk and Compliance Officer at dentalcorp. Kristy holds a Master of Science in Healthcare Quality from Queen’s University.
