March 06, 2022

What are Never Events in orthodontics?

Never events are actions, events, or failures that should never happen when protocols are followed. Researchers have developed these for medicine and surgery. This new paper outlined the development of never events for orthodontics. I thought that it was interesting. All orthodontists should read this paper.

The basis of never events is that we should develop plans to standardise how clinical activities are performed. In other words, never events help us protest the public. In addition, the development of never events, and methods to reduce them, allows us to set up reporting mechanisms to improve our clinical practice.

A team from New York did this research. The AJO-DDO published their paper.

Never events in clinical orthodontic practice

Laurence Jerrold and Jaclyn Danoff-Rudick

AJO-DDO advance publication,

Unfortunately, this paper is not open access, which is a shame. I wonder if the journal could make this paper to a wider group.

What did they ask?

They did this study to:

“Identify whether never events exist in orthodontic clinical practice”.

What did they do?

They based their study around a Delphi technique. This is a method of gathering the opinions of a group of people. Classically, we can divide this technique into several main stages. These are:

  • Identification of factors relevant to the clinical situation by collecting the opinion of a group of clinicians.
  • Presentation of these factors to a large group of clinicians. This group rates their strength of opinion on the elements or statements.
  • This may be followed by a further round. Finally, the opinions are recirculated to the group, and they are rescored.

The study team did a two-stage Delphi. In the first stage, they presented 10 orthodontists from diverse backgrounds with a few sample never event statements. Then the orthodontists used their personal experience to construct proposed never event statements. The research team then organised these responses to make 23 never events.

In the next stage, the team approached 65 orthodontists, who are members of a consortium of practitioners who agreed to participate in clinical orthodontic research. They asked the practitioners to agree or disagree with the provisional never statements.

Finally, they circulated circulating the events to a larger sample of practitioners recruited from orthodontic Facebook groups. This enabled the team to gather information from possibly thousands of practitioners. Then they used this data to identify never events supported by 95%, between 90% and 95%, and less than 90% affirmation.

What did they find?

Firstly, I will look at the response rates. In the second part of the Delphi, 25 out of 65 practitioners responded (38%). Unfortunately, they could not calculate a response rate for the final stage because they were not sure of the number of people who saw the survey request on Facebook. However, they received responses from 255 orthodontists throughout the World.

I will concentrate on the never events that obtained greater than 95% affirmation. Unfortunately, I do not have sufficient space to go through all the events. Therefore, I have also shortened the event information. I hope that you can understand this.  I have added some of my own comments in italics.

The never events

These were:

  1. We should never treat the wrong patient.
  2. All patients and personnel should never be subject to sexual harassment.
  3. We should not start treatment without an appropriate clinical examination.
  4. We should not start treatment without a medical history
  5. Patients should never be intentionally misled about the diagnosis, treatment plan and the expected benefits of treatment. Orthodontic breathing physicians and others on the “fringe”, watch out!
  6. The practitioner should never suggest the wrong tooth should be extracted.
  7. Apart from emergencies, we should not start treatment on minor children without parental or guardian consent.
  8. Radiographs should never be unread or unanalysed.
  9. We should not compromise treatment because of missing data or information.
  10. Patients should not be injured because of clinical neglect.
  11. Untrained or unlicensed personnel should never provide treatment.
  12. We must not start treatment without an established treatment plan. This does include a period of therapeutic diagnosis. Does this involve the current trend for same-day starts?

I also looked at the list of 90-95% affirmations. There were several other significant events, in my opinion. These were

  1. Radiographs should never be taken without assessing the need for the radiographs. This is relevant to those who take radiographs without examining the patient first.
  2. We should not expose patients to excess radiation unless there is a clear need for that exposure. I thought this was particularly relevant to orthodontists who happily take CBCT views on all their patients.
What did I think?

This is an important and clinically relevant paper. The study team followed established criteria for obtaining the information that they requested. I was impressed that their final sample of practitioners was substantial. In addition, their data analysis seemed good.

You may feel that this type of research is a bit imprecise. However, it is a method of gathering feelings. In this respect, it is very relevant for orthodontic clinical research. I cannot help thinking that this type of study is the future direction for orthodontic research.

When I looked at the events they identified, I agreed with most of them and did not strongly disagree with any of them. They provide a great starting point to consider strategies to protect our patients. I would suggest that the events are no problem for ethical practitioners.

Fitness to practice

This brings me to the problematic concept of whether this provides a framework for ethical practice. Importantly, we need to consider if non-compliance with these events reflects unethical practices. It is certainly possible that regulators could use the never events in fitness to practice proceedings. This is certainly worth debating. Let’s have a good chat about this interesting piece of work in the comments section of this blog.


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Have your say!

  1. Unique, remarkably interesting, and relevant. Thanks to Dr. Larry Jerrold (orthodontist, lawyer) and to Prof. O’Brien for his insights and comments.

  2. Did they consider never events induced by third party payer policies, social system limitations for treatment choices or corporate direct access to patients ?

  3. I think giving voice to Never Events is a fantastic idea whose greatest threats are stubbornness and fear:

    Don’t take away my separating pliers! I have used them for 20 years and NEVER had a problem…. which I know because I oversee each of my many assistants every time they place separators with the most unnecessarily dangerous instrument in orthodontics. I can’t be wrong about this because it has worked so well for so long… as far as I know.

    Over-regulation in the form of Never Events is just as scary as a giant snowball rolling downhill! The Covid Pandemic has taken a lot of control away from our lives and scared us into trying to control too much which can only backfire because we are giving outsiders like state governments ammunition to take even more control away from us… even though openly sharing and admitting that which should never happen in our profession only serves to protect us and our patients.

    I hope I am wrong and Never Events take root in our specialty.

  4. Not sure most of these are really never events, other than taking the wrong tooth out. This used to be a never event in the UK but has now been de-classified and no longer is one. As far as I understand a never event has to have serious consequencies and be a specific procedure, such as removing the wrong leg. Almost all of the listings are what would be called best clinical practice and apply to all specialities and are not specific enough to be called never events.

    • This is an interesting perspective. Hopefully, lead author Dr. Larry Jerrold will add his comments to your contrarian definition of “never events”.

    • Would have been more useful if that exercise had started wirh a clear definition of the term “never event “ .

  5. Finally something that is concise!! No more fine print.

  6. Dear Prof
    I personally need to have an OPG from each patient who seeks orthodontic consultation . I can not consider my examination proper and thorough without the initial OPG . Hence all my consult patients are advised to have an OPG at the consultation appointment . I appreciate if you can elaborate on this from your point of view .

    Kind Regards

  7. We are really in need of this forbidden orthodontic practice especially what has been going throughout our COVID era

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