945 Re-Audit of Incorrect Tcis; Are We Now Listing the Right Teeth. (4th May 2021)

• Record Type: Journal Article
• Authors: Matharu, K; Shah, A; Shorafa, M
• Is Part Of: British journal of surgery. Volume 108(2021)Supplement 2
• Publication Date: 2021-05-04
• Subjects: Surgery -- Periodicals; 617.005
• DOI: 10.1093/bjs/znab134.591
• Languages: English
• ISSNs: 0007-1323

Abstract

Abstract: Introduction: In 2018 in our OMFS out-patients department there were two wrong tooth extraction (WTE) events- at a Clinical Governance meeting we identified that TCI ('to come in' forms) were being completed incorrectly; from December 2018 to February 2019 there were 6 separate forms where the teeth listed for extraction was different to the teeth that were planned for extraction. As a result, our first stage audit involved data collection and root cause analysis of the incorrectly completed forms. As a result of the findings of the first stage audit, we decided to implement a change to TCI forms. Aim: To assess whether TCI forms were being correctly completed following on change to TCI forms. Data collection: Retrospective data collection from September 2019- January 2020 analysing any occurrences of incorrect TCI forms Results: No further incidents of incorrect TCI forms since September 2019 and WTE since the last occurrence in 2018. Conclusions: Although an incorrect TCI form was not listed as a potential cause for the two WTE events that occurred within the department, incorrect documentation is a known risk factor for WTEs. This completed audit cycle demonstrates successful learning from the WTEs and the implementation of beneficial changes.