Breaking the error chain with SEE: cascade analysis of endodontic errors in clinical training

References

• Estrela C, Pécora JD, Estrela CR, et al. Common operative procedural errors and clinical factors associated with root canal treatment. Braz Dent J. 2017;28(2):179–12. doi: 10.1590/0103-6440201702451
   PubMedGoogle Scholar
• Alrahabi M, Zafar MS, Adanir N. Aspects of clinical malpractice in endodontics. Eur J Dent. 2019;13(3):450–458. doi: 10.1055/s-0039-1700767
   PubMedGoogle Scholar
• Alghamdi NS, Algarni YA, Ain TS, et al. Endodontic mishaps during root canal treatment performed by undergraduate dental students: an observational study. Medicine. 2021;100(47):e27757. doi: 10.1097/MD.0000000000027757
   PubMed Web of Science ®Google Scholar
• Sowmya M, Raghu S. Clinical practice guidelines on endodontic mishaps that occur during cleaning and shaping. IJDOS. 2021;8(8):3607–3612. doi: 10.19070/2377-8075-21000738
   Google Scholar
• Doyal L, Cannell H. Whistle blowing: the ethics of revealing professional incompetence within dentistry. Br Dent J. 1993;174(3):95–101. doi: 10.1038/sj.bdj.4808094
   PubMed Web of Science ®Google Scholar
• Foy HM, Evans S. Teaching technical skills—errors in the process. Surgical Pitfalls E-Book: Disaster Prev Manag. 2008;11.
   Google Scholar
• Runciman W, Edmonds M, Pradhan M. Setting priorities for patient safety. BMJ Qual Saf. 2002;11(3):224–229. doi: 10.1136/qhc.11.3.224
   Google Scholar
• Pronovost PJ, Faden RR. Setting priorities for patient safety: ethics, accountability, and public engagement. JAMA. 2009;302(8):890–891. doi: 10.1001/jama.2009.1177
   PubMed Web of Science ®Google Scholar
• Obadan EM, Ramoni RB, Kalenderian E. Lessons learned from dental patient safety case reports. J Am Dent Assoc. 2015;146(5):318–26. e2. doi: 10.1016/j.adaj.2015.01.003
   PubMed Web of Science ®Google Scholar
• Kalenderian E, Walji MF, Tavares A, et al. An adverse event trigger tool in dentistry: a new methodology for measuring harm in the dental office. J Am Dent Assoc. 2013;144(7):808–814. doi: 10.14219/jada.archive.2013.0191
   PubMed Web of Science ®Google Scholar
• Kimura Y, Tonami K-I, Toyofuku A, et al. Analysis of incident reports of a dental university hospital. Ijerph query. 2021;18(16):8350. doi: 10.3390/ijerph18168350
   Google Scholar
• Akiyama N, Akiyama T, Sato H, et al. Comparison of physicians’ and dentists’ incident reports in open data from the Japan Council for quality health care: a mixed-method study. BMC Oral Health. 2023;23(1):1–8. doi: 10.1186/s12903-023-02749-x
   PubMed Web of Science ®Google Scholar
• Thusu S, Panesar S, Bedi R. Patient safety in dentistry–state of play as revealed by a national database of errors. Br Dent J. 2012;213(3):E3–E. doi: 10.1038/sj.bdj.2012.669
   PubMed Web of Science ®Google Scholar
• Woolf SH, Kuzel AJ, Dovey SM, et al. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Anna Family Med. 2004;2(4):317–326. doi: 10.1370/afm.126
   PubMed Web of Science ®Google Scholar
• Dovey S, Fryer G, Green L, et al. Toxic cascades. A comprehensive way to think about medical errors. Am Fam Physician. 2001;63(5):847.
   PubMed Web of Science ®Google Scholar
• Mold JW, Stein HF. The cascade effect in the clinical care of patients. Mass Medical Soc. 1986;314(8):512–514. doi: 10.1056/NEJM198602203140809
   Google Scholar
• Godfrey-Faussett P. The HIV prevention cascade: more smoke than thunder? Lancet HIV. 2016;3(7):e286–e8. doi: 10.1016/S2352-3018(16)30062-5
   PubMed Web of Science ®Google Scholar
• Herbst S, Herbst C, Schwendicke F. Preoperative risk assessment does not allow to predict root filling length using machine learning: a longitudinal study. J Dent. 2023;128:104378. doi: 10.1016/j.jdent.2022.104378
   PubMed Web of Science ®Google Scholar
• Haug SR, Solfjeld AF, Ranheim LE, et al. Impact of case difficulty on endodontic mishaps in an undergraduate student clinic. J Endod. 2018;44(7):1088–1095. doi: 10.1016/j.joen.2018.03.012
   PubMed Web of Science ®Google Scholar
• Duigou C. Discuss the prevention and management of procedural errors during endodontic treatment. Aust Endod J. 2004;30(2):74–78. doi: 10.1111/j.1747-4477.2004.tb00188.x
   PubMedGoogle Scholar
• Hofer TP, Kerr EA, Hayward RA. What is an error? Eff Clin Pract. 2000;3(6):261–269.
   PubMedGoogle Scholar
• Rotstein I, Ingle JI. Ingle’s endodontics. Raleigh, NC, USA: PMPH USA; 2019.
   Google Scholar
• Kurt M, Kurt S. Improving design understandings and skills through enhanced metacognition: reflective design journals. Int J Art Des Educ. 2017;36(2):226–238. doi: 10.1111/jade.12094
   Web of Science ®Google Scholar
• Qutieshat AR, Salem A, Kyranides MN, et al. Personality, learning styles and handedness: the use of the non‐dominant hand in pre‐clinical operative dentistry training. Eur J Dent Educ. 2021;25(2):397–404. doi: 10.1111/eje.12616
   PubMed Web of Science ®Google Scholar
• Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Acad Med. 2015;90(11):1471–1486. doi: 10.1097/ACM.0000000000000939
   PubMed Web of Science ®Google Scholar
• Alsofi L. Knowledge and understanding of endodontic concepts, working width vs working length and variable taper vs constant taper among endodontic practitioners. World. 2019;10(3):220. doi: 10.5005/jp-journals-10015-1635
   Google Scholar
• Kucher M, Dannemann M, Modler N, et al. An automated measurement method for the endodontic working width of lower molars by means of parametric models using cone-beam computed tomographcy and micro–computed tomography. J Endod. 2021;47(11):1790–1795. doi: 10.1016/j.joen.2021.08.004
   PubMed Web of Science ®Google Scholar
• Jou Y-T, Karabucak B, Levin J, et al. Endodontic working width: current concepts and techniques. Dent Clin North Am. 2004;48(1):323–335. doi: 10.1016/j.cden.2003.12.006
   PubMedGoogle Scholar
• Nagpal A, Hans MK. Working width–where to start and where to end? Dental Update. 2012;39(3):223.
   PubMedGoogle Scholar
• Ponce EH, Fernández JAV. The cemento-dentino-canal junction, the apical foramen, and the apical constriction: evaluation by optical microscopy. J Endod. 2003;29(3):214–219. doi: 10.1097/00004770-200303000-00013
   PubMed Web of Science ®Google Scholar
• ElAyouti A, Hülber-J M, Judenhofer MS, et al. Apical constriction: location and dimensions in molars—a micro–computed tomography study. J Endod. 2014;40(8):1095–1099. doi: 10.1016/j.joen.2013.12.002
   PubMed Web of Science ®Google Scholar
• Aminoshariae A, Kulild J. Master apical file size–smaller or larger: a systematic review of healing outcomes. Int Endod J. 2015;48(7):639–647. doi: 10.1111/iej.12370
   PubMed Web of Science ®Google Scholar
• Irby DM. What clinical teachers in medicine need to know. Acad Med. 1994;69(5):333–342. doi: 10.1097/00001888-199405000-00003
   PubMed Web of Science ®Google Scholar
• Shulman LS. Those who understand: knowledge growth in teaching. Educ Res. 1986;15(2):4–14. doi: 10.3102/0013189X015002004
   Google Scholar
• Makeham MA, County M, Kidd MR, et al. An international taxonomy for errors in general practice: a pilot study. Med j Aust. 2002;177(2):68–72. doi: 10.5694/j.1326-5377.2002.tb04668.x
   PubMed Web of Science ®Google Scholar
• Mahajan AS. Stress in medical education: a global issue or much ado about nothing specific? South-East Asian J Medl Educ. 2010;4(2):9–13. doi: 10.4038/seajme.v4i2.420
   Google Scholar
• Sturmberg J, Farmer L. Educating capable doctors—A portfolio approach. Linking learning and assessment. Med Teach. 2009;31(3):e85–e9. doi: 10.1080/01421590802512912
   PubMed Web of Science ®Google Scholar
• Givol N, Rosen E, Taicher S, et al. Risk management in endodontics. J Endod. 2010;36(6):982–984. doi: 10.1016/j.joen.2010.03.030
   PubMed Web of Science ®Google Scholar
• Gillis MR, McNally ME. The influence of industry on dental education. J Dent Educ. 2010;74(10):1095–1105. doi: 10.1002/j.0022-0337.2010.74.10.tb04964.x
   PubMed Web of Science ®Google Scholar