1. Call for a standard framework for Clinical Risk Management
program to ensure patient safety in Dentistry.
Author: Dr. Shoeb Ahmed Ilyas BDS, MPH, EMSRHS, M.Phil. (HHSM), MHRM, MS (PSY), MS
(BIOTECH), PGDMLE, FHTA.
Health Care Quality Management Consultant
Ruby Med Plus, Telangana State, India.
Globally, the patient safety movement got focused in risk management by the publication of “To
Err Is Human: Building a Safer Health System”, in 1999, which articulated the findings of a
study of Institute of Medicine (IOM) of the devastating consequences of widespread medical
error in the hospitals in USA. In addition to the unfortunate health consequences of medical
error, there are direct and indirect costs borne by society as a whole. Patient Safety is the
fundamental of the health care system. If care is not provided in a safe manner in a safe
environment, the chances for a good outcome are lessened significantly.
As, Institute of Medicine (IOM) noted, “Patients should not be harmed by the care that is
intended to help them, nor should harm come to those who work in health care.” The goal of risk
management in health care must be to prevent harm from reaching patients and those involved in
providing care to those patients and the place where the care is being providedi
. The aim of
Clinical Risk Management is to improve both the safety and quality of care for patients and to
reduce the costs of such risks for health care providersii
” Hence, the Clinical Risk Management
program needs a standard framework to fulfill this objective of Clinical Risk Management in
clinical Dentistry. It gives the realization to the Dentist / Dental Team that fallibility is part of the
human condition and human condition can’t be changed, but the conditions under which people
work can be changed. That explains the need of Clinical Risk Management in Dentistry.
Key Approaches to Clinical Risk Management (CRM) –
A more comprehensive definition of Clinical Risk Management is ‘an approach to improving
quality in health care which places special emphasis on identifying circumstances that put
patients at risk of harm, and then acting to prevent or control those risks.’iii
An ‘adverse event’—–to be distinguished from an error (active or latent) has been defined as:
1) An unintended injury or complication which; 2) results in disability, death or
prolongation of hospital stay, and is (3) caused by the health care management rather than
the patient’s diseaseiv
.
It is important to clarify that not all adverse events are the result of errors and, conversely, not all
errors result in adverse events or harmful outcomes for patients. Furthermore, some adverse
events may hold as an ‘acceptable complication of treatmentv
’. For instance, an adverse drug
event (ADE), such as the development of severe side-effects to a correctly prescribed drug,

2. stands as just one example of an adverse event that may be deemed an ‘acceptable complication’
of Dental treatment. The cornerstone of effective CRM is the non punitive identification,
reporting and open disclosure of errors.vi
An important feature of Clinical Risk Management is that it takes as its starting point the
premise that ‘safety is everybody’s responsibility’, not just the responsibility of an elite few. The
reasoning behind this is that: Almost everyone working in Dental care about patient safety, in the
sense of wanting to do their best. Two key approaches are very important to know-
a) ‘Person Approach’- It has two key features: Firstly, it is often the best people who make
the worst mistakes—error is not the monopoly of an unfortunate few. Secondly, far from
being random, mishaps tend to fall into recurrent patterns. The same set of circumstances
can provide similar errors, regardless of the people involvedvii
.
b) A ‘System Approach’ - which takes as its basic premise that ‘humans are fallible and
errors are to be expected, even in the best organizations’ and does not seek to name,
blame, and shame. Rather it seeks to ‘discern and learn’ and to treat ‘“every defect as a
treasure’’ because each one presents us with an opportunity to improveviii
’.
Risk Identification, Reporting and Analysis-
Risk identification and analysis is central of any risk management program. A systematic method
for reporting adverse event, near miss, sentinel event etc. is at the heart of the risk identification
technique. A blame free voluntary reporting system is a prerequisite to have a good reporting
system. Both reactive and proactive tools are used for risk identification and analysis in order to
control them. Reactive tool is subsequent analysis of incidents in order to identify the causes.
Proactive tool is used to identify and to remove system’s critical points before the incident takes
place.
Education and Training-
Clinical Risk Management Program (CRMP) activities need to encompass the areas of
education, communication; clinical care; safe environment and technology to prevent clinical
riskix
Hence, CRMP provides education and training to all Dental staff in relation to Clinical
Risk Management to prevent incident from occurring. It includes risk reporting and analysis
training, manual handling training, education on team work etc.
Communication and Safe Environment-
Communication, as a risk reduction activity involves Dental patient and family interaction after
adverse event, communication between Dental staff and Dental departments on risk management

3. and overall open disclosure policy and process. The process for ensuring that all communication
is open, honest and occurs as soon as possible following an incident, complaint or claim is ready
to be implemented. A policy on communicating outcome of care to the patients that includes
disclosure of Dental errors is important. Unanticipated outcomes must be communicated to
patients/families and Dental errors will be disclosed according to Dental Hospital policies with
apology, but compensation will be only given upon the request by patient.
Conclusion-
Clinical Risk Management Program (CRMP) is a new concept in Dentistry and therefore it needs
guidelines, human and financial resources. To make the Clinical Risk Management an issue in all
the Dental health care facilities in India, the commitment and support of Dental Council of India
(DCI) and Indian Dental Association (IDA) is essential. The two principles which govern and
operate in Clinical Risk Management are:
1. Patient safety should be the first and foremost goal of any Dental Hospital.
2. In most cases, errors related to Dental treatment are due to defects in the system rather than to
the fault of individual Dental Staff. Hence, correcting the system is much more important and
effective than punishing Dentist/Dental Team. A cultural change is essential, we must learn to
acknowledge errors and learn from them and to follow Florence Nightingale’s ideas as put
forward more than centaury years ago: ‘It may seem a strange principle to be expressed, yet the
first requirement of a Hospital lies in avoiding damage to the sick.’

5. References-
i
Don Nielsen, M. (25, Aug, 2003). Helping you do what is best for your patients. AHA
news, American Hopital Association.
ii
Walshe, K., & Dineen, M. (1998). Clinical Risk Management. Making a difference?
The NHS Confederation. Birmingham: University of Birmingham.
iii
Victorian Government Department of Human Services. Sentinel event program: annual report
2004—2005. Melbourne: Rural and Regional Health and Aged Care Service Division, Victorian
Government Department of Human Services; 2005.
iv
Wilson R, Runciman W, Gibberd R, Harrison B, Newby L, Hamilton J. The quality in
Australian health care study. Med J Aust 1995;163(November):458—71.
v
McNeil J, Ogden K, Briganti E, Ibrahim J, Loff B, Majoor J. Improving patient safety in
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vi
Leape L, Woods D, Hatlie M, Kizer K, Schroeder S, Lundberg G. Promoting patient safety by
preventing medical error. J Am Med Assoc 1998;280(16):1444—7.
vii
Reason J. Human error: models and management. Br Med J 2000;320(7237):370—768.
viii
Walshe K. Medical accidents in the UK: a wasted opportunity for improvement? In:
Rosenthal M, Mulcahy L, Lloyd-Bostock S, editors. Medical mishaps: pieces of the puzzle.
Buckinhgam: Open University Press; 1999.
ix
Sedwick, J., & Prota, G. G. (2001). The health care risk management Professional. In
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X Verbano, C., & Turra, P. (2010). A human Factors and reliability approach to clinical
risk management: Evidence from Italian cases. Safety Science (48), 625-639.