Wrong site tooth extraction removed from Never Events list

News Published: 
24 February 2021


The Faculty of General Dental Practice UK (FGDP) has welcomed the removal of wrong site tooth extraction from NHS England’s list of Never Events.


The change will come into effect on 1 April, but has been confirmed in the latest revision to the Never Events list which was published earlier this week.


The NHS defines Never Events as incidents with “the potential to cause serious patient harm or death” that are “wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers”.


The amendment to the list was recommended by an interdisciplinary, multi-stakeholder working group convened by NHS Improvement, whose review found that the barriers available and in place to prevent occurrences of wrong site tooth extraction are insufficient to meet the Never Event definition.


The same recommendation has also been made by the Healthcare Safety Investigation Branch in its recently-published National Learning Report on investigations into Never Events, which details ten incident types across healthcare, including wrong site dental extraction, which it says do not meet the definition.


While this development means there are no longer any dentistry-specific mishaps classified as Never Events by the NHS, incidents of wrong site extraction are still classified as Patient Safety Incidents, and should continue to be reported, and managed, accordingly.



Former FGDP(UK) Dean, Mick Horton, represented the Faculty on NHS Improvement’s working group, and was also among those who developed the NHS Local Safety Standard for Invasive Procedures (LocSSIPs) toolkit, which is available on the FGDP website. He commented:


“I’m delighted that NHS England has acted swiftly to accept the recommendation that wrong site extraction should no longer be classified as a Never Event. However it remains vitally important to report and manage any instances as Patient Safety Incidents, and I would urge dental teams and practice managers to download and digest the ‘LocSSIPs’ toolkit in order to minimise the risk of wrong site extraction happening in their practice.”


The ‘LocSSIPs’ toolkit is available at https://www.fgdp.org.uk/sites/fgdp.org.uk/files/docs/news/2017/locssips%20toolkit%20dental%20extraction.pdf.


Further details of changes to the NHS Never Events list are available at https://www.england.nhs.uk/patient-safety/revised-never-events-policy-and-framework/.