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Attitudes Toward Patient Safety Standards

in U.S. Dental Schools: A Pilot Study

Peggy Leong, D.M.D., M.B.A.; Jay Afrow, D.M.D., M.H.A.; Hans Peter Weber,
D.M.D.; Howard Howell, D.D.S.
Abstract: The objective of this study was to assess the patient safety culture among students, staff, and faculty in seven U.S. dental
school clinics when compared to those from a similar study in twenty U.S. hospitals. A survey on patient safety culture developed by
the Agency for Healthcare Research and Quality (AHRQ) was used to measure attitudes towards patient safety by anonymous faculty,
students, and support staff members who work in the clinics of seven U.S. dental schools. This survey instru-ment was also
administered to staff at twenty U.S. hospitals. In three of the twelve sections of the survey (Overall Perceptions
of Safety, Management Support for Patient Safety, and Teamwork Across Units), dental school personnel responses rated
above the hospital benchmark results. In Section 2 (Frequency of Adverse Events Reported) and Section 4 (Organizational
Learning/ Continuous Improvement), average dental school responses were below those recorded for hospital personnel. The
overall score from the twelve sections of the survey indicated that patient safety attitudes of dental school participants were
higher than those of their hospital counterparts.
Dr. Leong is Health Sciences Clinical Professor, Preventive and Restorative Dental Sciences Department, School of Dentistry,
University of California, San Francisco; Dr. Afrow is Executive Director of Quality and Dental Director, Wentworth Douglass Hospital,
New Hampshire; Dr. Weber is Raymond J. and Elva Pomfret Nagle Professor of Restorative Dentistry and Biomaterials Sciences and
Chair of the Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine; and Dr. Howell is A.
Lee Loomis Professor of Periodontology, Acting Head of the Department of Oral Medicine, Infection,
and Immunity, and Dean for Dental Education, Harvard School of Dental Medicine. Direct correspondence and requests for
reprints to Dr. Peggy Leong, Preventive and Restorative Dental Sciences Department, School of Dentistry, University of
California, San Francisco, 707 Parnassus Ave., Box 0758, San Francisco, CA 94143; 415-514-0686 phone; 415-476-0858
Key words: patient safety, survey, dental schools, hospital benchmarks
Submitted for publication 6/6/06; accepted 12/3/07

P atient safety has been a concern of the United States

health care system since1 the early twen-tieth
of preventable adverse events is estimated to be be-
tween $17 billion and $29 billion per year, of which
century. The Flexner report on medical over half are health care costs.3 Another report from
education, published in 1910, and the Carnegie Johns Hopkins Childrens Center and the Agency for
Foundation report on dental education in the United Healthcare Research and Quality reviewed 5.7
States and Canada, written by William J. Gies 2 and million records of patients under nineteen years of
published in 1926, both spoke of the need for greater age who were hospitalized in 2000; these records
attention to patient safety. The Gies report, which were from twenty-seven states. Of the 52,000 chil-
brought about dental education as we know it today, dren identified by the researchers as being harmed by
made many recommendations, including calls for unsafe medical care during their hospital stay, 4,483
better cooperation between dentistry and medicine, suffered a fatal injury.4 As the complexity of care
expansion of dental research, and greater apprecia- provided by the health care system increases, the
tion by dental teachers of the biological and medical chance of error or failure also increases. Al-though
side of dentistry.2 Although many areas of medical the magnitude and complexity of patient safety issues
and dental care have progressed since then, the oc- in dentistry differ from those found in hospitals,
currence of errors or failures continues to challenge attitudes towards those safety issues have not been
health care providers. systematically explored in dental schools, and there is
In 1999, the Institute of Medicines report no published research that has quantified the type and
To Err Is Human: Building a Safer Health System number of adverse events that occur in dental care.
focused attention on the number and frequency of
errors in inpatient hospitals. This report stated that In general, mainstream organizations working
errors cause between 44,000 and 98,000 deaths every on patient safety problems in medicine have done
year in American hospitals. The total national cost little to study these issues and determine how they

April 2008 Journal of Dental Education 431

may impact the delivery of dental care in the United American Association of Ambulatory Health Centers.
States. It could be assumed that the morbidity, mor- As expected, the current dental school accreditation
tality, and financial impact of human error in the process focuses primarily on the educational out-
dental environment would be significantly less than comes of the school with limited attention to patient
that seen in medicine. This could be the reason why it safety issues. During the process, one dental school
is not considered a high priority in the health care withdrew from participation, so there were seven
environment. This lack of scrutiny, however, can give schools that participated in both the survey and the
dental providers a false sense of security. site visit. The Internal Review Board of Harvard
Errors can occur in the dental environment, but Medical School and the Harvard School of Dental
with the lower morbidity and mortality rates in dentistry, Medicine approved the study.
the benefit of preventing errors may be mea-sured by The survey instrument was developed by the
increased patient and employee satisfaction, reduced U.S. Agency for Healthcare Research and Quality
practice costs, improved practice reputation, and less (AHRQ) and is entitled Hospital Survey on Patient
stress on dental providers. The cost of fail-ures may not Safety Culture.6 The AHRQ-sponsored develop-
be only direct costs, but indirect ones also. The amount ment of this survey is part of its goal of supporting a
of lost business because of a poor reputation can be culture of safety and quality improvement in the
significant though hard to quantify in a dental practice. nations health care system. This survey was utilized
In most organizations, the cost of preventing failures is to measure the attitudes towards patient safety issues
significantly less than the cost of correcting the error of students, staff, faculty, and administrators in seven
after it occurs.5 U.S. dental schools.
The purpose of this study was to test the hy- The survey consisted of forty-eight randomly
pothesis that the patient safety culture in U.S. dental sorted questions from twelve areas of concern.
school clinics is less developed than in hospitals by These twelve areas are shown in Table 1.
utilizing a survey instrument developed to measure In 2003, a pilot test of the survey was con-
patient safety culture in U.S. hospitals. ducted, and completed surveys were received from
over 1,400 staff from twenty different hospitals
across the United States. Data from these pilot tests
Materials and Methods were analyzed, and average scores were calculated
for each of the twelve dimensions of safety culture in
Because of its impact on the U.S. dental work- order to allow health care organizations to make
force, U.S. dental schools teaching clinics were benchmarking comparisons against these pilot sites.
chosen as the patient care model for this study. A For this study, slight modifications were made to the
recruitment letter was sent in May 2005 to all U.S. survey instruments language to accommodate the
dental schools listed on the American Dental Educa- categories of health care workers within a dental
tion Association website. The recruitment letter was school. For example, the personnel descriptions were
addressed to the associate/assistant dean for clinical changed from physician and nurse to dentist and
affairs to invite his or her voluntary participation in hygienist.
this study. Participation included completing a survey The surveys were mailed to the dental schools
instrument and taking part in a one-day site visit by and returned to the investigators at the beginning of
the principal investigator and co-investiga-tor. Eight the site visits. Each of the seven participating dental
dental schools agreed to participate in this study. schools received fifty copies of the survey with a
Visits were carried out between August and cover sheet requesting demographic information
November 2005. about the school. Each survey instrument was com-
Dental schools are unique among U.S. health pleted anonymously. The results were compiled into
care educational sites. Unlike medical, nursing, and four categories: Dentists, Dental Students, Dental
pharmacy schools, dental schools are the only health Support Staff, and all Dental Schools combined. The
care educational sites that provide patient care within analysis utilized average percentage of positive
the schools. When the students from medi-cine, responses to the fifty-one survey questions.
nursing, and pharmacy interact with patients, they Based on the methodology utilized by the
provide the care in sites, such as hospitals, that have AHRQ, the percentage of positive responses defined
received some form of specific patient safety as agreeing or strongly agreeing with a positive state-
accreditation, such as The Joint Commission or the ment or disagreeing or strongly disagreeing with a

432 Journal of Dental Education Volume 72, Number 4

Table 1. AHRQs hospital survey on patient safety culture organized into twelve sections
1. Overall Perceptions of Safety
A10: It is just by chance that more serious mistakes dont happen around
here. A15: Patient safety is never sacrificed to get more work done.
A17: We have patient safety problems in this unit.
A18: Our procedures and systems are good at preventing errors from happening.
2. Frequency of Adverse Events Reported
D1: When a mistake is made but is caught and corrected before affecting the patient, how often is it
reported? D2: When a mistake is made but has no potential to harm the patient, how often is it reported?
D3: When a mistake is made that could harm the patient but does not, how often is this reported?
3. Supervisor Expectations and Actions Promoting Patient Safety
B1: My supervisor/manager/instructor says a good word when he/she sees a job done according to
established patient safety procedures.
B2: My supervisor/manager/instructor seriously considers staff suggestions for improving patient safety.
B3: Whenever pressure builds up, my supervisor/manager/instructor wants us to work faster, even if it means
taking shortcuts.
B4: My supervisor/manager/instructor overlooks patient safety problems that happen over and over.
4. Organizational Learning/Continuous Improvement
A6: We are actively doing things to improve patient
safety. A9: Mistakes have led to positive change.
A13: After we make changes to improve patient safety, we evaluate their effectiveness.
5. Teamwork Within Units
A1: People support one another in this unit.
A3: When a lot of work needs to be done quickly, we work together as a team to get the work
done. A4: In this unit, people treat each other with respect.
A11: When one area in the unit gets really busy, others help out.
6. Communication Openness
C2: People will freely speak up if they see something that may negatively affect patient care.
C4: People feel free to question the decisions or actions of those with more authority.
C6: People are afraid to ask questions when something does not seem right.
7. Feedback and Communication About Errors
C1: We are given feedback about changes put into place based on event
reports. C3: People are informed about errors that happen in this unit.
C5: In this unit, we discuss ways to prevent errors from happening again.
8. Nonpunitive Response to Errors
A8: Staff feel as if their mistakes are held against them.
A12: When an event is reported, it feels as if the person is being written up, not the
problem. A16: Staff worry that mistakes they make are kept in their personnel file.
9. Staffing
A2: We have enough staff to handle our workload.
A5: Staff in this unit work longer hours than is best for patient care. A7:
We use more agency/temporary staff than is best for patient care. A14:
We work in crisis mode, trying to do too much, too quickly.
10. Management Support for Patient Safety
F1: Management in this facility provides a work climate that promotes patient safety. F8:
The actions of management in this facility show that patient safety is a top priority.
F9: Management in this facility seems interested in patient safety only after an adverse event happens.
11. Teamwork Across Units
F2: Units in this facility do not coordinate well with each other.
F4: There is good cooperation among units that need to work together. F6:
It is often unpleasant to work with staff from other units in this facility.
F10: Units in this facility work well together to provide the best care for patients.
12. Handoffs and Transitions of Patients
F3: Things fall between the cracks when transferring patients from one unit to
another. F5: Important patient care information is often lost during shift changes.
F7: Problems often occur in the exchange of information across units in this
facility. F11: Shift changes are problematic for patients in this facility.

April 2008 Journal of Dental Education 433

negative statement for each group was determined. for all three study groups. Section 11 (Teamwork
If the percentage of positive responses was more Across Units) was rated higher than the benchmark
than 5 percent above the results of the hospital for the total group of respondents. As shown in Table
group, the results were considered above average. 2, the results in Section 2 (Frequency of Adverse
If the percentage of positive responses was more Events Reported) and Section 4 (Organizational
than 5 percent below the hospital group Learning/Continuous Improvement) showed that the
benchmark, it was considered below average. All average dental school responses were below average
results between 5 per-cent above or below the compared to the national benchmark. The remaining
benchmark were considered to be average.6 seven sections had results within five percentage
Data analysis of this study followed the points of the benchmark results.
method used by the Benchmark survey analysis When asked to give the overall grade for the re-
available at the AHRQ website.6 spondents organization on patient safety, 77 percent
of the subjects in this study graded their dental school
as Very Good to Excellent (Table 3). The national
Results benchmark was 62 percent. The response provided by
dental students averaged 7 percent in the Poor to
There were a total of 328 surveys completed Failing grading compared to 2 percent to 3 percent in
out of 350 surveys sent to the seven participating the other two groups of respondents. The national
U.S. dental schools. The sample included ninety- benchmark was approximately 8 percent.
two dentists, 107 dental students, and 129 support
staff. Demographics of the dental schools were as
The average class size was sixty-one students
per class with a range of thirty to eighty-five. There were two sections in the survey where
Two schools were state-supported, two were the dental school respondents gave less positive re-
partially publicly funded, and three were sponses than the benchmark group. The response
entirely privately funded. to the Overall Patient Safety Rating was more
In all seven dental schools, the clinic director positive than the benchmark response. Since there
was a dentist. are both strengths and weaknesses in using a
All of the schools had a person or committee survey tool to measure the culture of an
des-ignated to oversee quality assurance for the organization, more in-depth discussions on these
patient care clinics. issues with some policy implications follow.
The age of the schools ranged from three years
to over 100 years. Frequency of Reporting Patient
Data derived from the 328 subjects at the seven
dental schools were compared to the results from Safety Problems (Section 2 in
employees at twenty hospitals that participated in a Survey)
2003 pilot test of the AHRQs hospital survey on All three dental groups (faculty, staff, and
patient safety culture. stu-dents) surveyed gave less positive responses to
The survey instrument items were divided the three questions on the reporting of problems
into twelve sections for result tabulation, as shown than the medical benchmark. There could be
in Table 1. In the actual survey instrument, these several reasons for the less positive responses
items were arranged in a different order to reduce including the lack of a user-friendly reporting
the pos-sibility of the survey format leading the system in dental school clinics and the lack of
respondents towards preferred responses. feedback to all three dental groups about the
The average responses to each section within usefulness of incident reports and changes made to
the dental school community were first analyzed in reduce errors as a result of timely reporting.
total as one group. They were then separated in order This challenge has also been noted in the medi-
to look at each group (dentist, dental student, and cal community: Both doctors and nurses believe
dental staff) individually (Table 2). Sections 1 and 10 they should report most incidents, but nurses do so
(Overall Perception of Safety and Management more frequently than doctors. To improve incident
Support for Patient Safety) were rated above average reporting, especially among doctors, clarification is

434 Journal of Dental Education Volume 72, Number 4

needed of which incidents should be reported, the incidents included time constraints, unsatisfactory
process needs to be simplified, and feedback given to processes, and deficiencies in knowledge, cultural
reporters.7 In a collaborative hospital study, Evans et norms, inadequate feedback, beliefs about risk, and
al. reported that common barriers to reporting a perceived lack of value in the process.8

Table 2. Comparison of responses among respondent groups percentage of responses that were positive
Survey on Patient Safety: Composite Level Benchmarks: Dentists Dental Dental Responses
Culture Survey Dimension Average % Positive Responses (n=92) Students Support from Seven
in Twenty Hospitals (n=107) Staff U.S. Dental
(n=1419) (n=129) Schools
1. Overall Perceptions of Safety 56% 79% 63% 67% 68%
(+) (+) (+) (+)
2. Frequency of Adverse Events Reported 52% 46% 37% 46% 42%
(-) (-) (-) (-)
3. Supervisor Expectations and Actions 71% 78% 67% 75% 72%
Promoting Patient Safety (+) (0) (0) (0)
4. Organizational Learning/Continuous 71% 64% 55% 58% 60%
Improvement (-) (-) (-) (-)
5. Teamwork Within Units 74% 85% 74% 82% 78%
(+) (0) (+) (0)
6. Communication Openness 61% 66% 42% 54% 58%
(0) (-) (-) (0)
7. Feedback and Communication About Errors 52% 62% 38% 40% 49%
(+) (-) (-) (0)
8. Nonpunitive Response to Errors 43% 53% 35% 49% 47%
(+) (-) (+) (0)
9. Staffing 50% 62% 54% 50% 55%
(+) (0) (0) (0)
10. Management Support for Patient Safety 60% 83% 66% 73% 67%
(+) (+) (+) (+)
11. Teamwork Across Units 53% 69% 60% 53% 62%
(+) (+) (0) (+)
12. Handoffs and Transitions of Patients 45% 48% 46% 52% 47%
(0) (0) (+) (0)

(+)=results above average for benchmark

(0)=results average for benchmark
(-)=results below average for benchmark

If the percentage of positive responses was more than 5% above the results of the hospital group, the results were considered
above average. If the percentage of positive responses was more than 5% below the hospital group benchmark, it was consid-
ered below average. All results between 5% above or below the benchmark were considered to be average.

Table 3. Comparison of patient safety overall grading by individuals

Patient Safety Grade Average % Average % Faculty Dental Dental
Response Response Dentists Students Support
Across Twenty Across Seven Staff
U.S. Hospitals U.S. Dental Schools
A=Excellent 15% 25% 27% 24% 25%
B=Very Good 47% 52% 58% 46% 55%
C=Acceptable 30% 18% 13% 23% 17%
D=Poor 8% 4% 2% 6% 2%
F=Failing <1% 1% 0% 1% 1%

Question was Please give your work area in this organization an overall grade on patient safety.
April 2008 Journal of Dental Education 435
Dental schools involved in this study should ter, are relatively simple to score and code, and can
develop policies to reduce the barriers to timely re- determine the values and relations of variables and
porting of safety issues and create a safe constructs.10 Surveys can be generalized to other
environment for such reporting. members of the population studied and often to
other similar populations. They can be reused
Proactive Activities (Section 4 in easily and provide an objective way of comparing
responses over different groups, times, and places.
Survey) Surveys can sometimes be used to predict behavior
The dental school survey respondents rated and can help confirm and quantify the findings of
dental schools lower than the medical benchmark in qualitative research.10
the area of proactive activities toward patient safety. Weaknesses of the survey method include the
Few of the sites visited had a process in place to fact that surveys are just a snapshot of behavior at
summarize and trend patient safety incident data that one place and time. One must be careful about
would allow them to focus on preventive rather than assuming they are valid in different contexts. Surveys
reactive activities. Without the ability to notice posi- do not provide a description of a situation that is as
tive or negative trending of incident reports, any form rich as a case study. They also do not provide
of proactive efforts would be without direction. evidence for causality between surveyed constructs
The use of a prospective root cause analysis or that is as strong as a well-designed experiment.10
failure mode effects analysis (FMEA) originated in Given some similarity of direct patient care
the world of industry over thirty years ago and has between most dental school practices and ambulatory
been adopted into the world of health care. FMEA is care areas of hospitals, we believe this survey instru-
a systematic method of identifying and preventing ment is a useful tool in the study. However, given the
process errors before they occur by evaluating a high small number of dental schools participating in this
risk, high volume, or problem-prone activity before a study and the resulting small sample size, we realize
problem arises.9 Medical organizations use it in an the studys limited generalizability.
effort to reduce the possibility of errors. Its adop-tion
into dental education could have only a positive
impact on patient care and students. Conclusion
The data from this study demonstrate that there
Overall Patient Safety Rating are areas of perceived weakness in the patient safety
The dental school survey respondents rated the culture of the dental schools visited. By identifying
overall grade on their organizations patient safety these specific areas, it should allow the leadership of
higher than the benchmark. Reasons for this overall these participating organizations to focus their efforts
positive grade could include lower morbidity resulting on improving their patient safety culture.
from errors due to the nature of dental procedures; lack Since dental schools train future generations
of knowledge of overall reported incidents; and lack of of dental clinicians in the world, we hope this data
benchmarking information for respondents to evaluate will help schools initiate a review of their current
their organizations performance in patient safety. patient safety programs within their teaching
Despite an overall positive safety rating, par- clinics, as well as inspire additional research in
ticipating dental schools should seek to educate best practices for patient safety that will lead to the
their staff, students, and faculty on the need for development of new benchmarks for patient safety
improved monitoring, better reporting, and for the dental profession.
trending of patient safety issues. This work will
result in educators positive attitudes based on a
true understanding of the safety conditions of their
dental clinics and not from a lack of knowledge. The authors thank Laura Ebenstein for her
administrative assistance and data entry for this
study. Two of the authors were funded by a grant
Use of the Survey Method from the Department of Restorative Dentistry and
There are strengths and weaknesses in using a Biomaterials Sciences at the Harvard School of
survey approach in this study. The strengths include Dental Medicine.
the fact that surveys are relatively easy to adminis-

436 Journal of Dental Education Volume 72, Number 4

6. Agency for Healthcare Research and Quality. Hospital
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