Meeting report for January 2019

The fourth meeting of the 2018/ 2019 session was held in Lecture Theatre 2 of GDH on Tuesday 15th January 2019 commencing at 7pm.

Apologies were received from five members

The minutes of the previous meeting, published online were approved.

The President, Mr Roddy Black, welcomed the members and guests to the meeting.

He then introduced the speaker, Mrs Irene Black and asked her to give her address to the society entitled ‘Patient Safety in Dentistry – Room for Improvement?’

Mrs Black started by outlining what she was going to discuss and placing patient safety in the wake of the Francis report and the role of the Scottish Patient Safety Programme (SPSP).

Mrs Black then explained that she was only going to limit her discussion to Quality Improvement.

The ambition of the SPSP is to reduce the number of events which cause harm to people from healthcare delivered in any care setting. The programme started with Acute Services in 2008 and GDS in 2017. 1 in 10 patients experience an adverse event in an acute setting. In Dentistry we provide a wide range of treatment for almost everyone we see, we see high volumes of patients and many patients pay GDP for NHS Services. She then asked the audience to reflect on what harm can befall patients. She described four categories of harm: Physical, Psychological, Financial and Neglect and gave examples of each category and described the feelings these categories may arouse in patients.

She then discussed potential hazards related to dental treatment or care. She described a patient death that arose in 2016 where a patient had a CVA following interaction of miconazole and warfarin. The scale of t he problem is not known in Primary Dental Care as there is no official reporting system.

Mrs Black then discussed why things go right – ETTO (Efficiency – Thoroughness Trade Off) Principle, Erik Hollnagel 2009, and why Human Factors affect not only the people involved but the systems in place.

She described what she felt were the barriers to sharing / reporting problems and discussed why enhanced SEA reporting taking into account human factors is important. Reporting problems will require a change in culture. The beast systems allow for a positive experience. There is no blame apportioned, empowered to speak out, they allow sharing of ideas and experiences, opportunity to have views heard, involvement of decision making. All of this is easy to postulate but difficult to put into practice.

QiP should be used to ensure patient safety. Mrs Black asked the audience to define quality improvement. She then defined the meaning in terms of healthcare and described the six dimensions of healthcare quality as defined by The Institute of Medicine (Quality Improvement made Simple, Health Foundation 2013) safety, timely, effective, efficient, person-centred and equitable. She described the QI tools that can be used and the amended GDC regulations: – Criterion Based Audit, Peer Review, Enhanced SEA, Practice Based Research, Patient Safety Review (added 2017). 15 hours must be completed in 3 year cycle and there are financial incentives available to dentists. QiP is not instant problem solving but an improvement ‘journey’ based on Model for Improvement with an aim (which should be SMART -Specific, Measurable, Attainable, Realistic/Relevant and Time Bound) , measures ( outcome, process sand balancing) and changes using SAPD (study, act, plan, do). Mrs Black then described driver diagrams, care bundles, data collection, tests of change, PDSA cycle using examples of QiPs to illustrate them. Mrs Black reminded the audience small changes are tested. She then described barriers to change and finished by describing the reasons to engage with Quality Improvement – professional responsibility, new tools and more flexibility, working together enables us to share experiences etc.

Mrs Black was happy to answer questions.

Mr David Brunton proposed the vote of thanks and thanked the speaker for an interesting and enjoyable presentation. The president then asked the audience to thank the speaker in the usual manner and presented him with an Odontological Society paperweight.

Under AOCB the President reminded members that to get CPD for the meetings they have to sign in giving their contact email address, without this CPD certificates cannot be sent out. An email will be sent out following the meeting and members were asked to follow the instructions contained in to generate individual CPD certificates. He asked the members to remember not to sign up at the last minute as booking closed at 4pm.

He asked that any member wishing to propose another member for Honorary Membership status to contact the Secretary or any of the Council members with their nominee.

The Council wants to add information about the past presidents to the website. The President showed a list of past president for whom we would like information and asked members to contact a committee member or send it in via

He then informed the audience that the Annual Dinner will be held on Saturday 23rd February 2019 in the RCPS Glasgow. The cost will be £65. Dress code: Black Tie. There are restricted numbers. The proceedings of the raffle are going to the Prince and Princess of Wales Hospice.

The next meeting is on Tuesday 19th February 2019 and is the Presidential Address by Mr Roddy Black entitled “Dentures- the whole tooth and nothing but the truth”