Usher Institute

Dental list of bad practice has patient care at heart

Dental experts have drawn up a definitive list of scenarios that patients should never face in a bid to ensure excellent patient care worldwide.

The checklist – which includes failing to note patients’ allergies and not screening for mouth cancers during check-ups – is the first international agreement of its type in dentistry.

The experts say it could be a major step forward in improving patient wellbeing across the globe.

Quickly spot errors

Monitoring these events will allow clinicians to quickly identify serious errors in procedure and could enable health authorities to monitor dentists’ performance, researchers say.

The consensus refers to so-called never events – failures so severe that they should not happen under any circumstances when correct procedures are followed.  

Never events

Never events for doctors – such as performing surgery on the wrong part of the body or leaving surgical instruments in a patient after an operation – are well-established in medicine.

Until now, the same practice has not been widely used in dentistry, with safety guidelines varying throughout the world.

Never events are a vital way to flag failures in procedure that put patient safety at risk. By listing a consensus position on never events in dentistry, we hope that regulators and professional bodies will be able to assess the frequency of such events and reduce their occurrence.

Professor Aziz Sheikh Usher Institute, University of Edinburgh

Global consensus

Using electronic questionnaires, researchers led by the University of Edinburgh engaged an international panel of experts to develop a detailed list of never events for dentists. 

The agreed list covers routine assessments as well as surgery and includes equipment not being sterilised and dentists prescribing the wrong medication to children.


The consensus is published in the British Dental Journal and was funded by the Mexican National Council for Science and Technology (CONACYT).  

It was carried out in collaboration with researchers at Cardiff University and King’s College London.

Our definitive list of never events reflects a collaborative international effort to improve patient safety. We hope the list will improve care for all patients by creating an environment of openness where all members of the dental team can easily report adverse incidents.

Professor Raman Bedi King's College London and former Chief Dental Officer of England

Related links

Original paper