Extracting wrong tooth no longer considered ‘never event’

  • Date: 25 February 2021

WRONG-SITE tooth extraction has been removed from the NHS England Never Events list in a move that has been welcomed by the The Faculty of General Dental Practice UK.

The change was confirmed in the latest revision to the ‘never events’ list and will come into effect on 1 April. 

Never events are defined by the NHS as incidents with "the potential to cause serious patient harm or death" 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".

A working group convened by NHS Improvement conducted a review of the list and found that the barriers available and in place to prevent occurrences of wrong-site tooth extraction are insufficient to meet the never event definition. However, incidents of wrong-site extraction are still classified as patient safety incidents and should continue to be reported and managed accordingly.

Former FGDP(UK) Dean, Mick Horton, represented the Faculty on NHS Improvement working group, and was also among those who developed the NHS Local Safety Standard for Invasive Procedures (LocSSIPs) toolkit, which is available on the FGDP website. He commented: "I’m delighted that NHS England has acted swiftly to accept the recommendation that wrong site extraction should no longer be classified as a Never Event.

"However it remains vitally important to report and manage any instances as patient safety incidents, and I would urge dental teams and practice managers to download and digest the ‘LocSSIPs’ toolkit in order to minimise the risk of wrong site extraction happening in their practice."

MDDUS advises that even though a wrong tooth extraction is no longer a "never event", it warrants a serious untoward incident review and root cause analysis. A serious incident such as a wrong tooth extraction engages the professional (and statutory) duty of candour, with its necessary obligations.

This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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