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Vol. 3 No. 1 (2026)

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Submitted
August 12, 2026
Published
August 14, 2026

Copyright (c) 2026 samar Hamad Alomar, Asma Obaid Alenezi, Fawz Mufadhi Alanazi 

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This work is licensed under a Creative Commons Attribution 4.0 International License.

System Safety in the Dental Operatory: A Scoping Review of Strategies to Prevent Wrong-Site, Wrong-Procedure, and Wrong-Patient Errors

https://doi.org/10.64483/202631754
samar Hamad Alomar
AlNakheel Medical complex in Riyadh,Ministry of Health, Saudi Arabia
Asma Obaid Alenezi
AlNakheel Medical complex in Riyadh,Ministry of Health , Saudi Arabia
Fawz Mufadhi Alanazi 
AlNakheel Medical complex in Riyadh,Ministry of Health , Saudi Arabia

Corresponding Author(s) : samar Hamad Alomar

s-alomar@hotmail.com

Saudi Journal of Medicine and Public Health, Vol. 3 No. 1 (2026)

Abstract

Background: Wrong-site, wrong-procedure, and wrong-patient errors represent a significant and preventable category of adverse events in healthcare. In dentistry, wrong-tooth extraction remains the most frequently reported serious patient safety incident, with profound implications for patients, clinicians, and healthcare institutions. Despite increased attention to patient safety over the past decade, the implementation of systematic preventive strategies in dental settings—particularly in primary care—has lagged behind other healthcare sectors.


Aim: This scoping review aims to systematically examine and synthesize the available evidence on strategies designed to prevent wrong-site, wrong-procedure, and wrong-patient errors in the dental operatory, with a specific focus on interventions applicable across dental practices, dental schools, and dental hospitals.


Methods: A comprehensive scoping review was conducted, drawing upon peer-reviewed literature, clinical guidelines, and policy documents published between 2020 and 2026. The review employed a systematic search strategy across multiple databases, supplemented by hand-searching of reference lists and grey literature. Studies were included if they addressed preventive strategies for wrong-site, wrong-procedure, or wrong-patient errors in dental settings.


Results: The review identifies five principal categories of preventive strategies: (1) structured checklists and procedural protocols, including the WHO Surgical Safety Checklist, Local Safety Standards for Invasive Procedures (LocSSIPs), and computerized safety checklists; (2) the Universal Protocol framework, encompassing pre-procedure verification, timeout procedures, and site marking adaptations; (3) patient identification and verification systems; (4) human factors interventions addressing communication, hierarchy, and safety culture; and (5) emerging technological solutions, including artificial intelligence-based decision support systems. Evidence indicates that checklists can improve compliance with safety standards by up to 50%, though their effectiveness is contingent upon integration with a positive patient safety culture.


Conclusion: Preventing wrong-site, wrong-procedure, and wrong-patient errors in dentistry requires a multi-layered, systems-based approach that combines structured protocols, cultural transformation, and technological innovation. The successful implementation of these strategies depends on leadership commitment, staff engagement, and the cultivation of a blame-free culture that encourages incident reporting and continuous learning. Future research should focus on primary care dental settings, where the majority of dental care is delivered and where safety interventions remain understudied.

Keywords

patient safety, wrong-site surgery, dental errors, checklists, Universal Protocol, safety culture, human factors
Alomar, samar H., Asma Obaid Alenezi, & Fawz Mufadhi Alanazi . (2026). System Safety in the Dental Operatory: A Scoping Review of Strategies to Prevent Wrong-Site, Wrong-Procedure, and Wrong-Patient Errors. Saudi Journal of Medicine and Public Health, 3(1), 77–85. https://doi.org/10.64483/202631754
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