Abstract
Background: One of the mechanisms to guarantee the quality of health care is the analysis of adverse events. Oral rehabilitation area is one of the most prone given the complexity of its procedures. Purpose: To analyze the adverse events that occurred in the postdoctoral oral rehabilitation clinic of the Pontificia Universidad Javeriana Dental School in 2013. Methods: Of the 595 clinical records corresponding to all patients who completed their treatment in 2013, 590 met the requirement to be signed by patient and teacher. From the medical records that contained some reported adverse event, following information was recorded: demographic data of patients, type of adverse events reported, possible causes of this events and whether or if they are preventable. Results: In 36 (6.1 %) of the clinical histories analyzed, some report of an adverse event was found. Most frequent adverse event was loss of the restoration (42 %). The cause more frequent was the complete fracture of the restoration (19 %). 58 % of the cases were considered a preventable adverse event. In 61.1 % of the cases, the type of prosthesis affected were fixed denture-retained ones. Conclusions: Frequency of adverse events reported in the medical records of patients treated in the rehabilitation area is low. Considering its preventable characteristic, it is important to register and analyze them to ensure quality in patient care.
Organización Mundial de la Salud (OMS). La alianza mundial para la seguridad del paciente. La Investigación en Seguridad del Paciente. Mayor Conocimiento para una atención más segura [internet]. Ginebra, Suiza: OMS; 2008. Disponible en: http://www.who.int/patientsafety/information_centre/documents/ps_research_brochure_es.pdf.
García-Barbero M. La alianza mundial para la seguridad del paciente [internet]. Valencia, España: Consejo de Enfermería de la Comunidad Valenciana; 2007. Disponible en: http://www.portalcenova.es/es/grupos/biologicos/pacientes/alianza_mundial_seguridad_paciente.pdf
República de Colombia. Resolución 1446 del 8 de mayo de 2006. Sistema de Información para la Calidad y se adoptan los indicadores de monitoría del Sistema Obligatorio de Garantía de Calidad de la Atención en Salud [internet]. Bogotá, Colombia: Ministerio de Salud y Protección Social; 2008. Disponible en: https://www.minsalud.gov.co/Normatividad_Nuevo/RESOLUCI%C3%93N%201446%20DE%202006%20-%20ANEXO%20T%C3%89CNICO.pdf
Ministerio de Salud y Protección Social. Lineamientos para la implementación de la política de seguridad del paciente en la República de Colombia [internet]. Bogotá, Colombia: el Ministerio; 2008. Disponible en: http://www.acreditacionensalud.org.co/catalogodocsLineamientos%20politica%20seguridad%20paciente.pdf.
República de Colombia. Ley 1438, que establece el Sistema Obligatorio de Garantía de Calidad de la Atención en Salud. Bogotá, Colombia: Ministerio de Salud y Protección Social; 2011.
República de Colombia. Resolución 00002003 [internet]. Bogotá, Colombia: Ministerio de Salud y Protección Social; 2014. Disponible en: https://www.minsalud.gov.co/Normatividad_Nuevo/Resoluci%C3%B3n%202003%20de%202014.pdf
Perea-Pérez B, Labajo-González E, Santiago-Sáez A, Albarrán-Juan E, Villa-Vigil A. Analysis of 415 adverse events in dental practice in Spain from 2000 to 2010. Med Oral Patol Oral Cir Bucal. 2014 Sep; 19(5): 500-5. https://doi.org/10.4317/medoral.19601.
Tafur Gallego M, Camacho Alonso L, Mejía Morales S, González Moncada J, Huertas de Hoyos M. Frecuencia de eventos adversos de la terapia endodóntica y seguimiento de pacientes atendidos en el Posgrado de Endodoncia de la Pontificia Universidad Javeriana (2007-2008). Univ Odontol. 2014 Jul-Dic; 33(71): 98-107. http://dx.doi.org/1011144/Javeriana.uo33-71.feat
Tafur DJ, Ramírez GP, Cárdenas CA, Serrano JJ, Sarralde AL, Camacho SP, Rodríguez A, González J. Características y prevalencia de los eventos adversos presentados en la Clínica del Posgrado de Periodoncia de la Facultad de Odontología de la Pontificia Universidad Javeriana durante el período 2011-2012. Univ Odontol. 2016 Jul-Dic; 35(75). http://dx.doi.org/10.11144/Javeriana.uo35-75.cpea
Huertas MF, González J, Camacho S, Sarralde AL, Rodríguez A. Analysis of the adverse events reported to the office of the clinical director at a dental school in Bogotá, Colombia. Acta Odontol Latinoam. 2017 Apr; 30(1): 19-25.
Ozcan M. Fracture reasons in ceramic-fused-to-metal restorations. J Oral Rehabil. 2003 Mar; 30(3): 265-9. https://doi.org/10.1046/j.1365-2842.2003.01038.x
Oram DA, Davies EH, Cruickshank-Boyd DW. Fracture of ceramic and metallic ceramic cylinders. J Prosthet Dent. 1984 Aug; 52(2): 221-30.
Øilo G. Flexural strength and internal defect of some dental porcelain. Acta Odontol Scand. 1988 Oct; 46(5): 313-22. https://doi.org/10.3109/00016358809004782
Mackert JR, Williams AL. Microcracks in dental porcelain and their behavior during multiple firing. J Dent Res. 1996 Jul; 75(7): 1484-90. https://doi.org/10.1177/00220345960750070801
Felton DA, Kanoy BE, Bayne SC, Wirthman GP. Effect of in vivo crown margin discrepancies on periodontal health. J Prosthet Dent. 1991 Mar; 65(3): 357-64. doi: http://dx.doi.org/10.1016/0022-3913(91)90225-L
Reich S, Schierz O. Chair-side generated posterior lithium disilicate crowns after 4 years. Clin Oral Investig. 2013 Sep; 17(7): 1765-72. https://doi.org/10.1007/s00784-012-0868-0
Bailey E. Contemporary views of dental practitioners on patient safety. Br Dent J. 2015 Dec; 219(11): 535-9. https://doi.org/10.1038/sj.bdj.2015.920.
Dourado A, Reis A. Sistemas adhesivos. RODYB [internet]. 2006 May-Ago; 1(2): 13-28. Disponible en: http://www.rodyb.com/wp-content/uploads/2013/02/sistemas-adhesivos2.pdf
Pospiech P. All-ceramic crowns: Bonding or cementing? Clin Oral Investig. 2002 Dec; 6(4): 189-97. https://doi.org/10.1007/s00784-002-0183-2.
This journal is registered under a Creative Commons Attribution 4.0 International Public License. Thus, this work may be reproduced, distributed, and publicly shared in digital format, as long as the names of the authors and Pontificia Universidad Javeriana are acknowledged. Others are allowed to quote, adapt, transform, auto-archive, republish, and create based on this material, for any purpose (even commercial ones), provided the authorship is duly acknowledged, a link to the original work is provided, and it is specified if changes have been made. Pontificia Universidad Javeriana does not hold the rights of published works and the authors are solely responsible for the contents of their works; they keep the moral, intellectual, privacy, and publicity rights.
Approving the intervention of the work (review, copy-editing, translation, layout) and the following outreach, are granted through an use license and not through an assignment of rights. This means the journal and Pontificia Universidad Javeriana cannot be held responsible for any ethical malpractice by the authors. As a consequence of the protection granted by the use license, the journal is not required to publish recantations or modify information already published, unless the errata stems from the editorial management process. Publishing contents in this journal does not generate royalties for contributors.