Sir, the paper 'Developing agreement on never events in primary care dentistry: an international eDelphi study'1 makes a number of statements and conclusions regarding never events. The NHS has already defined a never event and compiled a list which includes wrong tooth extraction. The following conditions must all be met in order to define a never event:

  • Never events are patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers

  • Each never event type has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a never event

  • For each never event type, there is evidence that the never event has occurred in the past – for example, through reports to the National Reporting and Learning System (NRLS) – and that the risk of recurrence remains

  • Each never event type must be able to be clearly defined and its occurrence easily recognised – this requirement helps minimise disputes around classification, and ensures focus on learning and improving patient safety.

Serious harm is defined as: severe harm (patient safety incident that appears to have resulted in permanent harm to one or more persons receiving NHS-funded care); chronic pain (continuous, long-term pain lasting more than 12 weeks or beyond the time that healing post trauma or surgery should have occurred) or psychological harm; impairment to sensory, motor or intellectual function or impairment to normal working or personal life which is unlikely to be temporary (that is, has lasted or is likely to last for a continuous period of at least 28 days).

Never events are reportable and once they occur, follow a set series of formal reporting and enquiry events. Many of these listed above, although it is accepted should not occur, will not satisfy the requirements of a formal never event and are thus inappropriate to be labelled as such.

It is possible that the authors did not fully understand the formal process of a never event and have attempted to construct their own list which should more appropriately be labelled significant events.

The construction of this list in such a manner unfortunately does nothing to reduce the level of risk or harm to patients unless the events are placed in context. The first event (breaking the patient's jaw) which on the face of it sounds very serious may actually occur for a number of reasons (hypertrophy, developmental, pathological due to widespread infection, necrosis and a number of other reasons), none of which may be avoidable in the context of urgent and necessary treatment.

The FGDP(UK) has for the last three years been attempting to instigate a formal anonymous reporting structure for significant events in order to allow shared learning of why these occur and to mitigate their reoccurrence. Such a register of significant events would encourage reporting from the profession and allow sharing of data on the frequency of such occurrences.

A significant event may be defined as any event which has an outcome either beneficial or detrimental, which differs significantly from that expected.

Within general dental practice we have numerous unique situations daily, where a significant event can occur. It is not the occurrence of an event that is of concern, but more how that event is managed at that time and in the future. The main purpose of reporting should be to provide a pathway to reflective learning of significant events as well as the formation of a central register of those events occurring nationally.

Reflective learning has been shown to be an effective method of education. If carried out correctly the participant will describe what occurred, describe their thoughts and feelings at the time, explain what was good or bad about the experience, analyse the situation and draw conclusions from this. The final and possibly most important stage is to draw an action plan in order to take appropriate action if the event occurred again.

If we continue to produce lists of mistakes which can occur within our profession, we are ignoring the fact that we are humans, we can and do make errors, we do not set out to make these errors and in some circumstances, these are unavoidable. The environment in which we work may influence our decision process and to make a flat comment that something should or should not occur ignores these factors.

Our profession needs to work together to improve levels of care, but we need to achieve this by sharing information about when events do occur, not making the profession so defensive they become reluctant to carry out certain treatments for fear of retribution.

In summary, I would suggest renaming these as significant events where there are opportunities to share, educate and improve patient care. They are not never events and the only never event that has occurred is to label them as such!

The following two letters are in response to a letter 'Paediatrics: Breastfeeding and dental health' published in the BDJ on 22 June 2018 (BDJ 2018; 224: 917).