Records to include as a minimum, when carrying out extractions:

1. Diagnosis and prognosis of tooth in question
2. Gaining informed consent (Risks, benefits, alternatives etc)
3. Taking a medical, dental and social history
4. Carrying out all necessary special investigations
5. Carrying out the WHO surgical checklist* prior to extraction

*The world health organisation (WHO) checklist is the final check to confirm all the patient details are correct, for example:

• The right patient which can be confirmed with the name, date of birth, and NHS number. 
• Patient risk of complications peri-operatively due to medical history
• Confirm the tooth/ teeth to be extracted (charted and radiograph).  

The origin of the WHO form 

In 2007 the WHO launched the second patient safety challenge ‘safe surgery saves lives’. The aim of that project was to improve the safety of patients undergoing surgical procedures. The WHO gathered a panel of international experts to discuss what leads to unsafe surgery and how to prevent it. The panel included: anaesthetists, operating theatre nurses, surgeons, safety experts and other professionals and they came up with the surgical checklist. The WHO surgical checklist was then developed in 2009 with the aim of reducing the safety of local safety procedures.

Why is there a need for a WHO safety form?

As humans we are prone to error, this is related to a discipline called human factors.

Human factors are about “Enhancing performance through an understanding of the effects of teamwork, tasks, equipment workspace, culture and organisation on human behaviour and abilities, and the application of that knowledge in clinical settings” A Concordat from the National Quality Board.

It was found that 2700 patients suffer iatrogenic harm annually due to wrong site surgery [2]. It is also reported that the majority of errors are related to human factors rather than technical ability or inadequate knowledge [3]. 

So what is the evidence of this safety checklist?

The effect of the checklist was studied between 2007 and 2008 across 8 pilot hospitals in different cities including: London, Toronto, Seattle, New Delhi, Amman, Ifakara, Manila and Auckland. The research aimed to study the effect of the safety checklist under different healthcare settings, economic circumstances and diverse patient populations. The study found that the use of the WHO checklist reduced the rate of deaths and surgical complications by more than one third across all eight pilot hospitals [1]. Major complications dropped from 11% to 7%, and mortality reduced from 1.5% to 0.8% [1].

Note: The study does however state that these effects can be attributed to the Hawthorne effect (the alteration of behaviour by the subjects of a study due to their awareness of being observed). 

However, the literature provides plenty of evidence to prove the efficacy of the surgical checklist in enhancing surgical safety and reducing complications and mortality [4,5]. But, there are barriers to its implementation [4] for example:

• Additional administrative work
• Items in the checklist are skipped
• Not doing the checklist properly e.g. asking the patient about prior use of bisphosphonates
• Rushing the checklist
• Allowing interruptions 

Overall, the purpose of the WHO form is to reduce errors and adverse events, therefore, optimising patient safety. It also helps to mitigate complications of extraction by considering the relevant aspects of the medical history. The checklist also helps prevent wrong site extraction (WSE) by reconfirming the tooth or teeth, to be extracted. WSE is classed as a never event by the NHS.

Never events, cause harm to the patient, are clearly defined and entirely preventable.

Notes:

Notes should be comprehensive, concise and contemporaneous. Examples of what should be included are:

• The type of consent - and who consented e.g. the patient themselves
• Who the patient attended with (if present)
• Any updates to the patient’s medical history
• Any problems or updates to dental health ("patient complaint")
• Include other relevant history taken (e.g. anxiety and social)
• Any special investigations and their quality e.g. grade 1 radiograph + report findings
• Diagnosis and prognosis
• Treatment options that were discussed
• Patient preferences of treatment
• The procedure(s) carried out e.g. LA, extractions etc 
• What equipment was used
• Any complications (the patient should be informed and documentation made).
• If Haemostasis was achieved and if this required any medicaments or further assistance e.g. suture. 
• Post-operative instructions about bleeding, pain control and emergency number were provided.
• If the course of treatment is not complete the TCA (to come again) instructions should clearly instruct what is expected at the next appointment, both for yourself, and incase another dentist sees the patient. 
• Medications used or prescribed should have
  - The name (avoid brand name)
  - administered site if applicable
  - batch number
  - expiry date
  - dose and amount

Post-Op instructions

The below list, provides the common areas to be discussed with the patient:

Bleeding 

• It is normal to experience the saliva appearing pinky/ red.
• If the socket starts to bleed again, the provided bite packs should be moistened with clean water, squeezing out the excess and place on site for 10-20 minutes, whilst biting. If bite pack is not available, a clean handkerchief can be rolled up as an alternatively. If the bleeding does not stop, advice should be sought. An emergency contact and advice should be provided.

Pain control

• You may experience pain, in particular during for the first 48 hours; however, soreness can last up to a week after the extraction.
• Paracetamol and Ibuprofen can be taken together for pain control (see pharmacology topic area for details). Please follow the directions of your dentist/pharmacist. If in the circumstance were to arise where the patient is unable to take either of these, an alternatives should be sought

Avoid

• The patient should avoid disturbing the extraction site with e.g. with their tongue or fingers as this can disturb healing.
• Smoking, alcohol and exercise should be avoided for 2-3 days.
• Excessive spitting or vigorous rinsing in the first day should be avoided
• Chewing on affected site for the next two days isn't recommended.
• You may be numb in the area of the procedure for 3-4 hours (depending on the LA used, could be shorter or longer). Therefore, care should be taken by the patient, so they don't burn themselves with hot foods or drinks, and to avoid lip or cheek biting during this time.

Oral hygiene

• Clean the adjacent teeth the day after the extraction with a soft tooth brush and toothpaste, but be care is needed around the extraction site.

Jaw stiffness

• The patient may experience some jaw stiffness or have difficulty opening your mouth after the surgery, but this should subside after a couple of days. Eating a soft diet and avoiding excessive mouth opening is advised.

A leaflet can (and should ideally) be given to the patient which includes all the information discussed, alongside some spare bite packs to take home.