16.6 Communication, Teamworking, Human Factors & Raising Concerns

The Dental Team and Lines of Responsibility

Outcome A4.1 asks for an understanding of each member's role and responsibilities within the team and A4.3 for organisational structures and lines of responsibility.

Two rules govern the boundary:

1. Training, competence and indemnity. A registrant may carry out any task for which they are trained, competent and indemnified and which lies within their scope of practice. Scope is not a fixed list to be memorised so much as a framework governed by competence.
2. Delegation does not transfer responsibility for the overall care of the patient. A dentist who delegates a task remains responsible for the treatment plan and for having satisfied themselves that the delegate is competent.

Direct access allows patients to see a dental hygienist or dental therapist without first seeing a dentist, for treatment within that registrant's scope, provided they are trained, competent and indemnified and know when to refer.

Human Factors (Outcome A4.2)

Human factors is the study of how people interact with systems, equipment and each other, and how design can make error less likely and less harmful. It rests on the observation that competent, motivated people make predictable errors under predictable conditions.

Classifying error

System thinking

Reason's Swiss cheese model describes accidents as the alignment of holes in successive layers of defence: latent conditions (staffing, equipment, time pressure) line up with active failures (the individual error). The practical conclusion is that safety comes from more and better layers, not from asking people to try harder.

Contributory conditions to watch for are fatigue, time pressure, interruption, unfamiliar equipment, poor handover, and steep hierarchy that discourages a nurse from questioning a dentist.

Safety tools used in dentistry

• Pre-procedure pause / surgical safety checklist adapted for dentistry: correct patient, correct site, correct procedure, correct radiographs displayed, allergies and medical alerts confirmed.
• Site marking and independent confirmation before extraction — the tooth to be removed is confirmed against the chart, the radiograph and the consent form, out loud, with the nurse.
• SBAR for handover and escalation: Situation, Background, Assessment, Recommendation.
• Graded assertiveness for challenging a senior colleague: probe, then alert, then challenge, then emergency action ("I need you to stop"). Teaching this explicitly is what makes it usable when hierarchy is steep.
• Significant event analysis after an incident: what happened, why, what will change, and who will check it changed.

Never Events are serious, largely preventable incidents that should not occur where the available preventive measures have been implemented. In dentistry the classic example is wrong-tooth extraction, and it is prevented by system design rather than by exhorting individuals to concentrate.

Communication Within the Team

Outcomes A3.7–A3.9 apply to colleagues as much as to patients:

• Use structured handover (SBAR) rather than narrative.
• Close the loop on verbal instructions: the person receiving repeats back the drug, dose and route.
• Summarise the plan at the end of the consultation so that nurse, patient and clinician share the same understanding.
• Recognise the communication modes of the setting: written referral, telephone escalation, electronic record, team huddle — each has different reliability and different audit value.

Raising Concerns (Outcome A5.2)

GDC Standards for the Dental Team principle 8 requires registrants to raise concerns if patients are at risk, and makes clear that the duty is not discharged by silence or by informal conversation alone.

The expected sequence:

1. Raise it locally first where it is safe and appropriate — with the person concerned, the practice owner, the clinical lead or the practice's designated person.
2. Escalate if the concern is not addressed, or if raising it locally is not appropriate: to the commissioner or health board, the regulator of the provider (CQC or the devolved equivalent), or the GDC.
3. Document what you saw, when, whom you told and what happened next.
4. Do not wait for certainty. The duty is to raise a concern, not to prove misconduct; investigation is someone else's job.

Protections and supports:

• The Public Interest Disclosure Act 1998 protects workers who make a qualifying disclosure in the public interest from detriment or dismissal.
• Freedom to Speak Up Guardians exist across NHS organisations.
• Fear of the consequences, loyalty to a colleague, and assuming someone else has already reported it are the three commonest reasons concerns are not raised — and none of them is a defence.