Attitudes Toward Patient Safety Standards in

U.S. Dental Schools: A Pilot Study

Peggy Leong, D.M.D., M.B.A.; Jay Afrow, D.M.D., M.H.A.; Hans Peter Weber, D.M.D.;
Howard Howell, D.D.S.
Abstract: The objective of this study was to assess the patient safety culture among students, staff, and faculty in seven U.S.
dental school clinics when compared to those from a similar study in twenty U.S. hospitals. A survey on patient safety culture
developed by the Agency for Healthcare Research and Quality (AHRQ) was used to measure attitudes towards patient safety by
anonymous faculty, students, and support staff members who work in the clinics of seven U.S. dental schools. This survey instru-
ment was also administered to staff at twenty U.S. hospitals. In three of the twelve sections of the survey (Overall Perceptions
of Safety, Management Support for Patient Safety, and Teamwork Across Units), dental school personnel responses rated above
the hospital benchmark results. In Section 2 (Frequency of Adverse Events Reported) and Section 4 (Organizational Learning/
Continuous Improvement), average dental school responses were below those recorded for hospital personnel. The overall score
from the twelve sections of the survey indicated that patient safety attitudes of dental school participants were higher than those
of their hospital counterparts.
Dr. Leong is Health Sciences Clinical Professor, Preventive and Restorative Dental Sciences Department, School of Dentistry,
University of California, San Francisco; Dr. Afrow is Executive Director of Quality and Dental Director, Wentworth Douglass
Hospital, New Hampshire; Dr. Weber is Raymond J. and Elva Pomfret Nagle Professor of Restorative Dentistry and Biomaterials
Sciences and Chair of the Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine;
and Dr. Howell is A. Lee Loomis Professor of Periodontology, Acting Head of the Department of Oral Medicine, Infection,
and Immunity, and Dean for Dental Education, Harvard School of Dental Medicine. Direct correspondence and requests for
reprints to Dr. Peggy Leong, Preventive and Restorative Dental Sciences Department, School of Dentistry, University of
California, San Francisco, 707 Parnassus Ave., Box 0758, San Francisco, CA 94143; 415-514-0686 phone; 415-476-0858 fax;
Peggy.leong@ucsf.edu.
Key words: patient safety, survey, dental schools, hospital benchmarks
Submitted for publication 6/6/06; accepted 12/3/07

P
atient safety has been a concern of the United
States health care system since the early twen-
tieth century. The Flexner report1 on medical
education, published in 1910, and the Carnegie
Foundation report on dental education in the United
States and Canada, written by William J. Gies2 and
published in 1926, both spoke of the need for greater
attention to patient safety. The Gies report, which
brought about dental education as we know it today,
made many recommendations, including calls for
better cooperation between dentistry and medicine,
expansion of dental research, and greater apprecia-
tion by dental teachers of the biological and medical
side of dentistry.2 Although many areas of medical
and dental care have progressed since then, the oc-
currence of errors or failures continues to challenge
health care providers.
In 1999, the Institute of Medicines report
To Err Is Human: Building a Safer Health System
focused attention on the number and frequency of
errors in inpatient hospitals. This report stated that
errors cause between 44,000 and 98,000 deaths every
year in American hospitals. The total national cost
of preventable adverse events is estimated to be be-
tween $17 billion and $29 billion per year, of which
over half are health care costs.3 Another report from
Johns Hopkins Childrens Center and the Agency
for Healthcare Research and Quality reviewed 5.7
million records of patients under nineteen years of
age who were hospitalized in 2000; these records
were from twenty-seven states. Of the 52,000 chil-
dren identified by the researchers as being harmed
by unsafe medical care during their hospital stay,
4,483 suffered a fatal injury.4 As the complexity of
care provided by the health care system increases,
the chance of error or failure also increases. Al-
though the magnitude and complexity of patient
safety issues in dentistry differ from those found in
hospitals, attitudes towards those safety issues have
not been systematically explored in dental schools,
and there is no published research that has quantified
the type and number of adverse events that occur in
dental care.
In general, mainstream organizations working
on patient safety problems in medicine have done
little to study these issues and determine how they

April 2008 Journal of Dental Education 431

 may impact the delivery of dental care in the United
States. It could be assumed that the morbidity, mor-
tality, and financial impact of human error in the
dental environment would be significantly less than
that seen in medicine. This could be the reason why
it is not considered a high priority in the health care
environment. This lack of scrutiny, however, can give
dental providers a false sense of security.
Errors can occur in the dental environment,
but with the lower morbidity and mortality rates in
dentistry, the benefit of preventing errors may be mea-
sured by increased patient and employee satisfaction,
reduced practice costs, improved practice reputation,
and less stress on dental providers. The cost of fail-
ures may not be only direct costs, but indirect ones
also. The amount of lost business because of a poor
reputation can be significant though hard to quantify
in a dental practice. In most organizations, the cost of
preventing failures is significantly less than the cost
of correcting the error after it occurs.5
The purpose of this study was to test the hy-
pothesis that the patient safety culture in U.S. dental
school clinics is less developed than in hospitals by
utilizing a survey instrument developed to measure
patient safety culture in U.S. hospitals.
Materials and Methods
Because of its impact on the U.S. dental work-
force, U.S. dental schools teaching clinics were
chosen as the patient care model for this study. A
recruitment letter was sent in May 2005 to all U.S.
dental schools listed on the American Dental Educa-
tion Association website. The recruitment letter was
addressed to the associate/assistant dean for clinical
affairs to invite his or her voluntary participation
in this study. Participation included completing a
survey instrument and taking part in a one-day site
visit by the principal investigator and co-investiga-
tor. Eight dental schools agreed to participate in this
study. Visits were carried out between August and
November 2005.
Dental schools are unique among U.S. health
care educational sites. Unlike medical, nursing,
and pharmacy schools, dental schools are the only
health care educational sites that provide patient care
within the schools. When the students from medi-
cine, nursing, and pharmacy interact with patients,
they provide the care in sites, such as hospitals, that
have received some form of specific patient safety
accreditation, such as The Joint Commission or the
432
American Association of Ambulatory Health Centers.
As expected, the current dental school accreditation
process focuses primarily on the educational out-
comes of the school with limited attention to patient
safety issues. During the process, one dental school
withdrew from participation, so there were seven
schools that participated in both the survey and the
site visit. The Internal Review Board of Harvard
Medical School and the Harvard School of Dental
Medicine approved the study.
The survey instrument was developed by the
U.S. Agency for Healthcare Research and Quality
(AHRQ) and is entitled Hospital Survey on Patient
Safety Culture.6 The AHRQ-sponsored develop-
ment of this survey is part of its goal of supporting
a culture of safety and quality improvement in the
nations health care system. This survey was utilized
to measure the attitudes towards patient safety issues
of students, staff, faculty, and administrators in seven
U.S. dental schools.
The survey consisted of forty-eight randomly
sorted questions from twelve areas of concern. These
twelve areas are shown in Table 1.
In 2003, a pilot test of the survey was con-
ducted, and completed surveys were received from
over 1,400 staff from twenty different hospitals
across the United States. Data from these pilot tests
were analyzed, and average scores were calculated
for each of the twelve dimensions of safety culture
in order to allow health care organizations to make
benchmarking comparisons against these pilot sites.
For this study, slight modifications were made to the
survey instruments language to accommodate the
categories of health care workers within a dental
school. For example, the personnel descriptions
were changed from physician and nurse to dentist
and hygienist.
The surveys were mailed to the dental schools
and returned to the investigators at the beginning of
the site visits. Each of the seven participating dental
schools received fifty copies of the survey with a
cover sheet requesting demographic information
about the school. Each survey instrument was com-
pleted anonymously. The results were compiled into
four categories: Dentists, Dental Students, Dental
Support Staff, and all Dental Schools combined.
The analysis utilized average percentage of positive
responses to the fifty-one survey questions.
Based on the methodology utilized by the
AHRQ, the percentage of positive responses defined
as agreeing or strongly agreeing with a positive state-
ment or disagreeing or strongly disagreeing with a
Journal of Dental Education Volume 72, Number 4
Table 1. AHRQs hospital survey on patient safety culture organized into twelve sections
1. Overall Perceptions of Safety
A10: It is just by chance that more serious mistakes dont happen around here.
A15: Patient safety is never sacrificed to get more work done.
A17: We have patient safety problems in this unit.
A18: Our procedures and systems are good at preventing errors from happening.
2. Frequency of Adverse Events Reported
D1: When a mistake is made but is caught and corrected before affecting the patient, how often is it reported?
D2: When a mistake is made but has no potential to harm the patient, how often is it reported?
D3: When a mistake is made that could harm the patient but does not, how often is this reported?
3. Supervisor Expectations and Actions Promoting Patient Safety
B1: My supervisor/manager/instructor says a good word when he/she sees a job done according to established
patient safety procedures.
B2: My supervisor/manager/instructor seriously considers staff suggestions for improving patient safety.
B3: Whenever pressure builds up, my supervisor/manager/instructor wants us to work faster, even if it means taking
shortcuts.
B4: My supervisor/manager/instructor overlooks patient safety problems that happen over and over.
4. Organizational Learning/Continuous Improvement
A6: We are actively doing things to improve patient safety.
A9: Mistakes have led to positive change.
A13: After we make changes to improve patient safety, we evaluate their effectiveness.
5. Teamwork Within Units
A1: People support one another in this unit.
A3: When a lot of work needs to be done quickly, we work together as a team to get the work done.
A4: In this unit, people treat each other with respect.
A11: When one area in the unit gets really busy, others help out.
6. Communication Openness
C2: People will freely speak up if they see something that may negatively affect patient care.
C4: People feel free to question the decisions or actions of those with more authority.
C6: People are afraid to ask questions when something does not seem right.
7. Feedback and Communication About Errors
C1: We are given feedback about changes put into place based on event reports.
C3: People are informed about errors that happen in this unit.
C5: In this unit, we discuss ways to prevent errors from happening again.
8. Nonpunitive Response to Errors
A8: Staff feel as if their mistakes are held against them.
A12: When an event is reported, it feels as if the person is being written up, not the problem.
A16: Staff worry that mistakes they make are kept in their personnel file.
9. Staffing
A2: We have enough staff to handle our workload.
A5: Staff in this unit work longer hours than is best for patient care.
A7: We use more agency/temporary staff than is best for patient care.
A14: We work in crisis mode, trying to do too much, too quickly.
10. Management Support for Patient Safety
F1: Management in this facility provides a work climate that promotes patient safety.
F8: The actions of management in this facility show that patient safety is a top priority.
F9: Management in this facility seems interested in patient safety only after an adverse event happens.
11. Teamwork Across Units
F2: Units in this facility do not coordinate well with each other.
F4: There is good cooperation among units that need to work together.
F6: It is often unpleasant to work with staff from other units in this facility.
F10: Units in this facility work well together to provide the best care for patients.
12. Handoffs and Transitions of Patients
F3: Things fall between the cracks when transferring patients from one unit to another.
F5: Important patient care information is often lost during shift changes.
F7: Problems often occur in the exchange of information across units in this facility.
F11: Shift changes are problematic for patients in this facility.

April 2008 Journal of Dental Education 433

 negative statement for each group was determined. If
the percentage of positive responses was more than
5 percent above the results of the hospital group,
the results were considered above average. If the
percentage of positive responses was more than 5
percent below the hospital group benchmark, it was
considered below average. All results between 5 per-
cent above or below the benchmark were considered
to be average.6
Data analysis of this study followed the method
used by the Benchmark survey analysis available at
the AHRQ website.6
Results
There were a total of 328 surveys completed
out of 350 surveys sent to the seven participating
U.S. dental schools. The sample included ninety-
two dentists, 107 dental students, and 129 support
staff. Demographics of the dental schools were as
follows:
The average class size was sixty-one students per
class with a range of thirty to eighty-five.
Two schools were state-supported, two were
partially publicly funded, and three were entirely
privately funded.
In all seven dental schools, the clinic director was
a dentist.
All of the schools had a person or committee des-
ignated to oversee quality assurance for the patient
care clinics.
The age of the schools ranged from three years to
over 100 years.
Data derived from the 328 subjects at the seven
dental schools were compared to the results from
employees at twenty hospitals that participated in
a 2003 pilot test of the AHRQs hospital survey on
patient safety culture.
The survey instrument items were divided into
twelve sections for result tabulation, as shown in
Table 1. In the actual survey instrument, these items
were arranged in a different order to reduce the pos-
sibility of the survey format leading the respondents
towards preferred responses.
The average responses to each section within
the dental school community were first analyzed in
total as one group. They were then separated in order
to look at each group (dentist, dental student, and
dental staff) individually (Table 2). Sections 1 and
10 (Overall Perception of Safety and Management
Support for Patient Safety) were rated above average
434
for all three study groups. Section 11 (Teamwork
Across Units) was rated higher than the benchmark
for the total group of respondents. As shown in Table
2, the results in Section 2 (Frequency of Adverse
Events Reported) and Section 4 (Organizational
Learning/Continuous Improvement) showed that the
average dental school responses were below average
compared to the national benchmark. The remaining
seven sections had results within five percentage
points of the benchmark results.
When asked to give the overall grade for the re-
spondents organization on patient safety, 77 percent
of the subjects in this study graded their dental school
as Very Good to Excellent (Table 3). The national
benchmark was 62 percent. The response provided
by dental students averaged 7 percent in the Poor to
Failing grading compared to 2 percent to 3 percent
in the other two groups of respondents. The national
benchmark was approximately 8 percent.
Discussion
There were two sections in the survey where
the dental school respondents gave less positive re-
sponses than the benchmark group. The response to
the Overall Patient Safety Rating was more positive
than the benchmark response. Since there are both
strengths and weaknesses in using a survey tool to
measure the culture of an organization, more in-
depth discussions on these issues with some policy
implications follow.
Frequency of Reporting Patient
Safety Problems (Section 2 in
Survey)
All three dental groups (faculty, staff, and stu-
dents) surveyed gave less positive responses to the
three questions on the reporting of problems than the
medical benchmark. There could be several reasons
for the less positive responses including the lack of
a user-friendly reporting system in dental school
clinics and the lack of feedback to all three dental
groups about the usefulness of incident reports and
changes made to reduce errors as a result of timely
reporting.
This challenge has also been noted in the medi-
cal community: Both doctors and nurses believe
they should report most incidents, but nurses do so
more frequently than doctors. To improve incident
reporting, especially among doctors, clarification is
Journal of Dental Education Volume 72, Number 4
needed of which incidents should be reported, the incidents included time constraints, unsatisfactory
process needs to be simplified, and feedback given to processes, and deficiencies in knowledge, cultural
reporters.7 In a collaborative hospital study, Evans norms, inadequate feedback, beliefs about risk, and
et al. reported that common barriers to reporting a perceived lack of value in the process.8

Table 2. Comparison of responses among respondent groups percentage of responses that were positive
Survey on Patient Safety: Composite Level Benchmarks: Dentists Dental Dental Responses
Culture Survey Dimension Average % Positive Responses (n=92) Students Support from Seven
in Twenty Hospitals (n=107) Staff U.S. Dental
(n=1419) (n=129) Schools
(n=328)

1. Overall Perceptions of Safety 56% 79% 63% 67% 68%

(+) (+) (+) (+)
2. Frequency of Adverse Events Reported 52% 46% 37% 46% 42%
(-) (-) (-) (-)
3. Supervisor Expectations and Actions 71% 78% 67% 75% 72%
Promoting Patient Safety (+) (0) (0) (0)
4. Organizational Learning/Continuous 71% 64% 55% 58% 60%
Improvement (-) (-) (-) (-)
5. Teamwork Within Units 74% 85% 74% 82% 78%
(+) (0) (+) (0)
6. Communication Openness 61% 66% 42% 54% 58%
(0) (-) (-) (0)
7. Feedback and Communication About Errors 52% 62% 38% 40% 49%
(+) (-) (-) (0)
8. Nonpunitive Response to Errors 43% 53% 35% 49% 47%
(+) (-) (+) (0)
9. Staffing 50% 62% 54% 50% 55%
(+) (0) (0) (0)
10. Management Support for Patient Safety 60% 83% 66% 73% 67%
(+) (+) (+) (+)
11. Teamwork Across Units 53% 69% 60% 53% 62%
(+) (+) (0) (+)
12. Handoffs and Transitions of Patients 45% 48% 46% 52% 47%
(0) (0) (+) (0)

(+)=results above average for benchmark

(0)=results average for benchmark
(-)=results below average for benchmark

If the percentage of positive responses was more than 5% above the results of the hospital group, the results were considered
above average. If the percentage of positive responses was more than 5% below the hospital group benchmark, it was consid-
ered below average. All results between 5% above or below the benchmark were considered to be average.

Table 3. Comparison of patient safety overall grading by individuals

Patient Safety Grade Average % Average % Faculty Dental Dental
Response Response Dentists Students Support
Across Twenty Across Seven Staff
U.S. Hospitals U.S. Dental Schools

A=Excellent 15% 25% 27% 24% 25%

B=Very Good 47% 52% 58% 46% 55%
C=Acceptable 30% 18% 13% 23% 17%
D=Poor 8% 4% 2% 6% 2%
F=Failing <1% 1% 0% 1% 1%

Question was Please give your work area in this organization an overall grade on patient safety.

April 2008 Journal of Dental Education 435

 Dental schools involved in this study should
develop policies to reduce the barriers to timely re-
porting of safety issues and create a safe environment
for such reporting.
Proactive Activities (Section 4 in
Survey)
The dental school survey respondents rated
dental schools lower than the medical benchmark in
the area of proactive activities toward patient safety.
Few of the sites visited had a process in place to
summarize and trend patient safety incident data that
would allow them to focus on preventive rather than
reactive activities. Without the ability to notice posi-
tive or negative trending of incident reports, any form
of proactive efforts would be without direction.
The use of a prospective root cause analysis or
failure mode effects analysis (FMEA) originated in
the world of industry over thirty years ago and has
been adopted into the world of health care. FMEA
is a systematic method of identifying and preventing
process errors before they occur by evaluating a high
risk, high volume, or problem-prone activity before
a problem arises.9 Medical organizations use it in an
effort to reduce the possibility of errors. Its adop-
tion into dental education could have only a positive
impact on patient care and students.
Overall Patient Safety Rating
The dental school survey respondents rated the
overall grade on their organizations patient safety
higher than the benchmark. Reasons for this overall
positive grade could include lower morbidity resulting
from errors due to the nature of dental procedures; lack
of knowledge of overall reported incidents; and lack of
benchmarking information for respondents to evaluate
their organizations performance in patient safety.
Despite an overall positive safety rating, par-
ticipating dental schools should seek to educate their
staff, students, and faculty on the need for improved
monitoring, better reporting, and trending of patient
safety issues. This work will result in educators
positive attitudes based on a true understanding of
the safety conditions of their dental clinics and not
from a lack of knowledge.
Use of the Survey Method
There are strengths and weaknesses in using a
survey approach in this study. The strengths include
the fact that surveys are relatively easy to adminis-
436
ter, are relatively simple to score and code, and can
determine the values and relations of variables and
constructs.10 Surveys can be generalized to other
members of the population studied and often to other
similar populations. They can be reused easily and
provide an objective way of comparing responses
over different groups, times, and places. Surveys
can sometimes be used to predict behavior and can
help confirm and quantify the findings of qualitative
research.10
Weaknesses of the survey method include the
fact that surveys are just a snapshot of behavior at one
place and time. One must be careful about assuming
they are valid in different contexts. Surveys do not
provide a description of a situation that is as rich
as a case study. They also do not provide evidence
for causality between surveyed constructs that is as
strong as a well-designed experiment.10
Given some similarity of direct patient care
between most dental school practices and ambulatory
care areas of hospitals, we believe this survey instru-
ment is a useful tool in the study. However, given the
small number of dental schools participating in this
study and the resulting small sample size, we realize
the studys limited generalizability.
Conclusion
The data from this study demonstrate that there
are areas of perceived weakness in the patient safety
culture of the dental schools visited. By identifying
these specific areas, it should allow the leadership of
these participating organizations to focus their efforts
on improving their patient safety culture.
Since dental schools train future generations
of dental clinicians in the world, we hope this data
will help schools initiate a review of their current
patient safety programs within their teaching clinics,
as well as inspire additional research in best practices
for patient safety that will lead to the development
of new benchmarks for patient safety for the dental
profession.
Acknowledgments
The authors thank Laura Ebenstein for her
administrative assistance and data entry for this
study. Two of the authors were funded by a grant
from the Department of Restorative Dentistry and
Biomaterials Sciences at the Harvard School of
Dental Medicine.
Journal of Dental Education Volume 72, Number 4

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