Interview: 'Human error is inevitable'

Dental Tribune ONLINE: Every dentist placing implants is confronted with the possibility of errors at some stage. What are the most common, and at what procedural stage do they usually occur?
Dr Mark Pinsky: Multiple studies have demonstrated consistently that placing dental implants is safe, practical and efficient. It is a very important restorative dental tool. The interesting thing about this question is that it leads one to the approach of “If I only do something this way and not that way, I will have solved the problem”. When thought of in a prospective fashion, errors should be considered threats. The common theme associated with all errors is that, upon analysis, there is always a human associated with it.

The reality is that errors can occur at any phase of implant placement. They vary in degree of severity and effect on long-term survival, but it is in the constant study of the elements that make up the field of human factors related to error that threats will be trapped at a stage where the long-term consequences of an error are less significant or mitigated.

A US study from 2012 has suggested that errors are more likely to occur when clinicians have less than five years of clinical experience. How relevant are operative procedural errors compared with other errors?
There are actually a number of studies on error, and experience should definitely be considered a component. However, there is a paradox here, as inexperience may mean that the operator does not know what he is doing, or it may mean that he slows down and is more careful. Conversely, the experienced operator may know what he is doing, but be more prone to certain errors because he is so ingrained in his behavioural patterns that he does not recognise the error.

Human error is inevitable. No amount of experience or lack of it can change this fact.

Do you consider behavioural patterns a significant risk factor?
I would prefer to use the term “human factors”. One must identify individual behavioural patterns, both good and bad, to deconstruct a procedure into its individual components and identify areas of risk. Furthermore, one must look at the surgical implant team and its dynamics, breaking it down into small units to aid in potential risk mitigation.

This is a very dynamic situation; it is never static. One begins by looking prospectively, and identifying potential threats. Then one changes the associated behavioural pattern. Over time, one looks retrospectively to see if the change was effective. Meanwhile, the process continues. It is the establishment of fundamental behavioural patterns that allows for a safe method to introduce new materials or procedures.

Periodontal disease and lack of healthy bone structure are some of the most important risk factors for implant failure. Are these still overlooked in your opinion, and what do we know at this point about their significance?
Periodontal disease and lack of healthy bone structure are indeed important for predicting implant success. There are potential other risk factors as well, of which one must always be aware. They can be thought about as something determined at the population level and not at the individual level. For example, a typical risk factor statement would take the following form: when we looked at x number of patients that we did y to, we found z. The individual operator then can make decisions armed with this knowledge.

The interesting thing about risk factors is that there is an implied uncertainty associated with the term. Risk cannot exist without uncertainty. It is up to each operator to ensure that risk is identified and quantified prior to a procedure, and then all effort is made to mitigate that risk during a procedure. This will ensure a more predictable outcome.

Should there generally be more focus on prevention of these risks?
So far, it is intuitively obvious that prevention is the key, as it minimises the longer-term exposure to the risk associated with more significant procedures. The logic goes like this: if you prevent periodontal disease, you will prevent bone loss, which will prevent the loss of a tooth, which will prevent the need for an implant, which most likely will, but may not, work. This will never change. The better the long-term data, the easier it will be to incorporate that information into the early phases of a well-thought-out prevention programme prior to the need for treatment. This clearly identifies the need for post-operative data to make preoperative decisions to determine risk. The only way to determine long-term success effectively is to identify which components of a procedure work and which do not. Collecting effective long-term data is the next logical step in the process of minimisation of error.

Successful prevention depends to a large extent on better diagnostics. Are dentists currently up to date in this field, and what tools are available to avoid potential errors before treatment even begins?
I only partially agree with this assertion. Better diagnostics is simply a group of better informational tools that presents some aspect of specific information better than before to the dentist. Successful prevention really depends on what the practitioner does with that information. Better information will only make for improved prevention if there is a system in place to capture the information and ensure its use every time. How many of the people reading this have a drawer somewhere in their office full of new items that they tried but no longer use?

Implant planning with CBCT has become very popular and an increasing number of dentists have access to it. Would you consider the technology to be such a system?
The product that CBCT provides is information. Some of the information corroborates what a dentist can determine through conventional methods, while some is unique to CBCT. The ALARA principle dictates that CBCT be used when the information gleaned from the radiation exposure outweighs the risk.

The information potential from a CBCT scan is truly remarkable. Since CBCT has a risk associated with it, it should be incorporated into the overall risk management strategy. The potential advantages lie in its proper use of the vast amount of single-source information it potentially has. The risk is that CBCT becomes the default standard for every issue without proper consideration for each specific case.

Risk assessment protocols are becoming increasingly important in general dentistry for identifying and managing oral diseases like caries. Should the same principles be applied to dental implantology as well?
Absolutely. It is through the identification and subsequent mitigation of risk through robust risk management strategies that success rates will improve. Risk assessment protocols, like CBCT, are a tool in the bag of tricks a dentist uses to narrow the variability and make an outcome more predictable.

Speaking of risk assessment protocols, there really is one risk factor that is more important than any other with regard to dental implantology. That is how the operator feels at the time she is placing the implant. This is closely related to the concept of situational awareness. While this may seem a bit abstract, it is through the loss of situational awareness that one will not recognise or react inappropriately to all other risk factors. Examples include when the operator is in a hurry, or is tired, or is worrying about the next case, or anything else that takes away from the focus at hand.

How can loss of situational awareness be minimised?
In an article in the Journal of the American Dental Association on which I was lead author, we introduced a universal dental checklist. No professional pilot would ever take off or land a plane without using a checklist, no matter how many times he or she has done it. The World Health Organization has promoted a surgical checklist to be used in hospital operating rooms with great success. The same should hold true for dentistry as well. Consistent use of a dental checklist is a good start at recognising the human aspect of providing dentistry, for every patient every time. No exception.

Thank you very much for the interview.