#227 Patient Safety: Lessons from 2025

In this episode, the Divas reflect on the year’s most impactful safety challenges and breakthroughs. We'll highlight key takeaways you can carry forward into 2026, reinforcing a culture of vigilance and trust. Join us as we distill the lessons of the past year into practical strategies for a safer tomorrow.

• Dental Patient Safety Foundation: https://www.dentalpatientsafety.org/
• TDIC, Improving Patient Safety with a Timeout Policy: https://www.tdicinsurance.com/Manage-Risks/RM-Matters/Article/improving-patient-safety-with-a-timeout-policy

                                                 https://www.thecompliancedivas.com

Transcript

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SPEAKER_02 0:04

Welcome. I'm Leslie Cannon. I'm Mary Gavoni. I'm Linda Harvey.

SPEAKER_01 0:10

I'm Olivia Wan, and together we are the Compliance Divas. Welcome to the Compliance Divas Podcast. This is Linda Harvey, and I will be your moderator for this episode's. You know, in the past, the divas have talked about patient safety, and we realize that it's become more than a checklist. It's a global movement that's been reshaping the way care is being delivered for over 25 years. When at that time, what began as a call to action to reduce errors, it really evolved into a culture of transparency, accountability, and continuous improvement. So today, the Divas are going to share with you some patient safety issues we've seen throughout the year and offices that we've worked with. Mary, can I ask you to kick us off with something that you saw this year that was concerning, or maybe it was a near-miss?

SPEAKER_00 1:04

Sure, Linda. And I guess I would consider the couple of incidents that I've seen this year and in previous years as near misses. In setting up treatment rooms, some of the team members in a couple of different practices were opening up pouches, putting instruments on the tray, and setting the pouches aside as opposed to throwing them away, which actually kind of worked in their favor because it was a good lesson that they learned. So when they're cleaning up the treatment room and they're taking instruments and things out, they saw on the pouches that the indicators had not changed, which meant then that those instruments may not have been exposed to all the parameters needed for having sterile instruments for sterilization. So then that sparks a whole dilemma of what do we do? Do we talk to the patient and say, we're very sorry that this error occurred, but we're not sure that the instruments were sterile that we used for your treatment, which certainly could incite some panic on the part of the patient. The CDC has very specific guidance as to what uh someone should do, what a healthcare facility should do if they suspect non-sterile instruments or some kind of an exposure happened. So I would we'll put that in the show notes. I would refer to that. And also, that is something that a practice would want to talk to their malpractice insurance company about as to how to word this. If you contact the patient, what are the right verbal skills to use so that you don't set off alarm bells? And certainly, if a patient wants to go and be tested for HIV or hepatitis B or C, we would pay for that and reassure them that there's really very little chance of exposure, but offer that to them so that we don't create a lot of ill will. But the bottom line is that before those instruments get put into storage or placed into a treatment room to be used, we need to check the indicators on the pouches. And of course, remembering that we should be putting an integrator into each load, that that's the first thing we check when we open up the sterilizer and finish the dry cycle. We check the integrator to make sure it passed, make sure the pouches are dry, and make sure all the indicators have changed. Now, in another instance, and I know that that I've had a lot of feedback from practices just one last week where I was doing training, where the practice gives the patient safety glasses to wear to protect their eyes, and patients resisted. And in one instance, the patient got some acidetch solution when they were rinsing the tooth off, splashed in their eye, and it was very uncomfortable. They had to get the patient up out of the chair, take the patient to the eye wash station, and then they recommended just as a precaution that they go and see their ophthalmologist or optometrist after that incident. So no matter how much pushback that your patient gives you, tell them this is for your safety. We don't want to have an instrument get dropped and poke you in the eye, we don't want you to get any solutions in your eyes, and don't make it a choice. This is our policy. And sometimes we have to be really firm with patients rather than just dismiss it if they say, Well, I don't really don't want to wear them. No, you need to wear them. And it's interesting because in a medical setting, when we're told we have to do something, we do it, but we have never, I don't think, been forceful enough in dentistry to say, this is what you need to do. And I think we can do it gently, and we can do it in a um in an assertive manner without making the patient feel like they're being bullied. But you know, we do this for a reason. And if the patient objects, then get the doctor in to assert their authority.

SPEAKER_01 5:35

Thank you, Murray. Those are two good examples of things that you've seen throughout the year, and I'm sure Leslie and I have, and Olivia as well have seen something similar. But it reminds me when you talk about the sterilization pouches of how every little detail matters in instrument processing. So the thought came to me when a new team member is being on boarded, whether they have experience or not, but perhaps especially if they're brand new to dentistry, is to really instill that point in their minds from the very beginning. Always check along the way when you're unloading the autoclave, when you're putting instruments away, when you're opening instruments. There's several points that Dr. James Reason and some of the other human engineering philosophers and studies who wrote research on all these topics, talk about having barriers in place. Swiss, the Swiss cheese barriers that help protect. And of course, as we know, the Swiss cheese has holes. And when those holes, which is the opportunity for air, line up, that's when injury occurs to the patient. So having different barriers, you know, which is a point in time where you're looking and checking for these different forms, particularly with instruments, is very important. And the eyewear, I would love to have a conversation a future time with the divas about communication with patients because it is about the communication, how we say what we say, to get them to be compliant with the eyewear and not asking them, would you like to put on our glasses? Here are our glasses. This is part of if they say some, you know, what do you say when they push back? Because again, it might be a new team member or someone who's young and not comfortable pushing back on a patient. So some very important pieces, Mary, to keep in mind. Thank you for sharing. And I also want to share to step back to our and talk to our listeners briefly, just what is a near miss? Where it was all familiar to us in our lingo as consultants, but a near-miss has been defined as an opportunity for error, but you catch it, so it could also be called a good catch before it actually reaches the patient. So for in that case of instruments being opened and put on a tray and then the pouch being put to the side, if someone then double checked the assistant herself or maybe the doctor when they walked in, or a second assistant, there's an opportunity you catch it before the non-stentially non-sterile instruments were used on the patient. That's a near-miss or a good catch. So thanks for those, Mary. Leslie, tell us please, what have you seen this year that has been concerning for patient safety? We should be aware of.

SPEAKER_02 7:58

Well, the first thing I want to do is say that I've seen plenty of instruments that don't have the color change. And so there are many near misses that are occurring. Just to recap what Mary said, everybody and yourself should be checking. Everyone has a role in infection control from the person who processes the instruments and removes them from the sterilizer to the person who stages the instruments to the person who is the operator or the clinician, making sure that everybody has done their part because it's an easy thing to have slip. I have also seen a lot of debris on instruments, and that's something that's not only this year, but in previous years. And you know, we already know that if you don't clean debris off of instruments, that what's underneath it will be protected from your steam, your chemical vapor, or the heat of your sterilizer. So that's something that seems to come up on an ongoing basis, as well as uh compromised instrument pouches. I've seen sterile instruments that have been uh poked through or breached the pouch. So they're no longer sterile. And when we're seeing more and more invasive procedures, and particularly in dental offices that are performing implants, we want to make sure that those instruments and devices that we use are sterile. Another patient safety issue that I see is as we are moving into the colder weather and we have those rain mats in our front door, and we have sometimes the mats just inside of our reception area to wipe the feet and the leaves and the snow and everything else. Those little corners of those mats can turn up pretty easily, and it's very easy to trip and fall over one of those mats that's not completely flat. I've also seen that uh carpeting. Sometimes we neglect our carpeting a bit. I've seen some tears that could uh catch the toe of a shoe and have a patient go straight down from the reception area upon entry to the clinical area. And I think these are areas that uh we don't see because we're there every single day and we're we miss that that spot on the rug or that hole and the tear of the carpet or or any of the other little things that are housekeeping issues, frankly, that uh we because we're there every day, it just becomes uh normalized in our mind. But uh as consultants, we go into dental offices and we see all these little things that could be safety hazards.

SPEAKER_01 10:27

Leslie, thank you for sharing those patient safety concerns. And and I think it is important that we bear in mind that patient safety isn't just in a treatment room, it's throughout the entire practice. So coming in safely and securely and not tripping as you fall into the office is very important as well. The the two patient safety items that I wanted to share today for our listeners, the first one is relative to sedation. With so many dental practices providing different levels of sedation to patients in their practice, particularly oral sedation, I wanted to mention a scenario where something to keep in mind. If you if the patient arrives at the office with their driver and then the office administers the oral sedation, and what if the patient has to continue waiting in the reception area till their operator is ready? I know one situation recently where the patient actually fell asleep in the reception area, fell out of the chair, did some stitches and was injured. So it was just one of those unfortunate situations that you didn't think would happen because the patient's sitting there with their driver. So I would like to recommend to our listeners to please evaluate that in your practices, whether you work in a general practice with sedation or a periodontal practice or oral surgery. Where is the patient sitting and waiting once they've been sedated in your office with oral sedation before you're ready for to begin their procedures? So please bear that in mind. And along those lines with different types of sedation and everything, we have to have all those emergency medical drugs. And frequently throughout the year, I'm seeing expired emergency medical drugs in the kit, as well as the AED pads that are expired. Now, if Russ here in Florida and many other states, it's a law that we have to have an AED pad. That's not fall, that's not fall under OSHIF RUS in Florida, doesn't fall under OSHIF or anyway, it's a state law, but it falls under our dental practice act. So immediately that will jeopardize the doctor's license, especially if they have a medical emergency and the AED doesn't work. So I want to remind everyone to put that on their year-end task list or throughout the year, conduct regular checks of your sedation carts, your emergency medical drugs, and your AED, along with your emergency oxygen tanks. Divas, do you have any other thoughts or suggestions to share?

SPEAKER_02 12:50

Well, Linda, you bring up something that kind of gives me a giggle. I do a little bit of a sweep through the uh anesthetic and the expired pharmaceuticals, things like that, just like you do when I consult with an office. And and you know, over the last couple of years I paid particular attention to AED pads and expired AED pads. And I was checking in one office as an AED machine that I was not familiar with, and I accidentally set off the AED alarm and the voice, you know, the voice prompts, and everybody, you know, stepped out of their operatories as a fairly large dental group. And so it was a bit embarrassing, but uh yeah, that is important to know where to look for the AED expiration dates on the pads. I also do want to emphasize that another near miss that could occur is expired anesthetic, particularly the anesthetic that we use infrequently, if it's something that is uh has no epi in it or short-acting. Sometimes those anesthetic corpyls sit in the rooms or in the drawers, but they don't get used. So we find that they're expired. And I don't know truly how long that uh the life, uh the shelf life is beyond an expiration date and whether that would be something that would be a severe patient safety issue. Something else I thought it would be important to mention, and I know we're going to be doing a future podcast on this with patient communication. As a hearing-impaired individual, uh, I know sometimes I say, yes, I understood something when I really didn't. You know, sometimes it's embarrassing to say what over and over again, or to have instructions repeated to me multiple times. And so sometimes patients will misunderstand what is being said, and it can really jeopardize their patient safety because it may be home care instructions that are important, particularly following surgery or extractions, you know, don't use a straw and don't rinse out the cloth, things like that. Uh, or it can be medication instructions where they may misunderstand what their responsibility is, what they need to do with uh the dosage or the frequency of taking medication. Uh, it can also be something that can be kind of uncomfortable at the front desk is that they misunderstand financial arrangements and you think that you've made clear, concise uh agreement with the patient, and they're nodding their heads yes and saying, okay, okay, or I understand, but they don't. And so I just want to remind everybody that uh making sure that you confirm that your patient has understood those very important instructions that you provide for them, ask them if they can repeat back what they heard or you know, something to confirm in your mind that those instructions are understood, maybe even provide that information in writing so that you can confirm for the patient who's embarrassed to say that they didn't understand it the second or third time that you've explained it. Uh, please make sure that they absolutely do make us certain that you've uh taken that extra step.

SPEAKER_01 15:59

Leslie, I think you hit the nail on the head with the communication, and that's the risk communication to me and is one of my favorite topics. So I can't wait to uh uh create a podcast on this topic because there's so much when it comes to patient safety and communication. And we know just in general, in any healthcare setting, particularly dental, communication is utmost importance. So I thank the divas for sharing their mishaps and near misses and best practices for patient safety today and things that they've seen throughout the year. I hope this information is helpful in your practices as you strive to continue to reach new heights with patient safety and keeping it top of mind and continuing to build trust with your patients along the way. As the compliance divas, we bring clarity and simplicity to compliance by navigating the regulatory world to keep you on track. We invite you to subscribe to our podcast through your favorite podcast channel or on our website, thecompliancedivas.com. Questions are welcome. You may submit them to support at the compliance divas.com. You'll find some resources in today's show notes. And also, we would love for you to scroll down and drop us your best tip or concern for patient safety. We'd love to hear what's on your mind as well. And we'll look forward to seeing you in the next episode.