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8½ Tips for Dental Safety Checklists by Captain Stephen W. Harden, BS, ATP, B-737, B-727, MD-11 and John B. Roberson, DMD

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More than 3,000 hospitals around the world have registered with the World Health Organization (WHO) to implement the use of a pre-procedure safety checklist. This is not surprising given the widely publicized data proving the use of safety checklists reduces complications, errors, infections and mortality. With documented results like these, more than 300 professional societies, health organizations, ministries and non-governmental organizations have endorsed the concept of using checklists to provide safe care.

Dental practices are also taking advantage of safety checklists to make dental care safer for their patients, and more efficient, profitable and trouble-free for their offices. How? Proactive dental offices are using a detailed checklist protocol similar to the safe surgery checklist developed by the WHO - which is itself based on the checklists that professional pilots have used for years to prevent human error and accidents. The aviation checklist system has significantly reduced airline mishaps.

Dentists are finding that checklists work as well in their practices as they do in commercial aviation. It's not hard to see why. Both professions rely on teamwork and attention to detail to achieve the best result. And, both have serious consequences for human error.

The dental checklist system is used to failsafe personnel, equipment and data. It helps office staff to think ahead during each case and catch errors early in the processes used in dental practices. Catching human error becomes very important as one unchecked early error can snowball into a catastrophe for dental patients, especially if the practice is using conscious sedation. One error caught early not only prevents catastrophe and lawsuits, it also improves the efficiency of office operations. Thus, safety checklists are not only the right thing to do for patient safety, they are the right thing to do for a practice's bottom line.

A professor of dentistry and two practicing dentists - who are also commercial airline pilots - spearheaded the development of by Captain Stephen W. Harden, BS, ATP, B-737, B-727, MD-11 and John B. Roberson, DMD the dental checklist system. They created a checklist that optimally standardizes dental procedures for pre-emptive error discovery.

Their checklist is categorized into five typical timeframes:
  • Appointment summarization
  • Prior to procedure
  • During procedure
  • Prior to patient release
  • Following patient release

Using this checklist system as a starting point, each dental practice adapts and revises the checklist to fit its own office procedures and culture. The customized, office-specific checklist establishes standard, optimum protocols.

While creating and implementing a safety checklist seems intuitively easy, experience has shown that implementation mistakes are common and can ruin the effectiveness of checklists. Having helped more than 110 organizations around the world create and successfully implement checklists, author Harden offers eight tips to boost the success rate of the checklist implementation process in dental practices.

Tip 1: Ensure your checklist is user-built and maintained.

The most important phrase on the current WHO Surgical Safety Checklist is located on the bottom of the page: "This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged." Administrators ignore this piece of advice at their peril. Effective checklists borrow heavily from the "Kaizen" methodology of the Toyota Manufacturing Process. In Kaizen, the people who actually do the work are best suited and most responsible for creating the standard for how the work is accomplished. Checklists created by other people at other facilities will rarely work well. There is no emotional investment and no pride of authorship in an "offthe- shelf " checklist.

To overcome this, put a small team together with representatives from each work group that will participate in using the dental safety checklist. Allow them the freedom to customize the tool in a way that makes sense for them and that aids their work flow. As an administrator, give them the resources and support they need to be successful, then get out of their way and allow them to do their customization. Want to avoid the "not made here" syndrome and all the problems that it brings? Ensure your checklist is built and implemented by your clinical staff - not your administrators, and certainly not the staff from a different facility.

Tip 2: Keep it short.

Not everything has to be on a dental safety checklist. Checklists are used to verify only the critical items of a procedure. Critical items are those that if not done correctly will cause harm to patients or caregivers before that error can be stopped. For example, there are approximately 65 items for an airline captain to check to prepare a modern airliner for engine start and flight. However, most "before start" checklists have only 11 or 12 items to be reviewed. These are the items, that if missed, will not be self-correcting before some harm to the aircraft, passengers or crew is caused. With checklists, shorter is better.

Tip 3: Don't confuse your checklist with an audit tool.

Great checklists are not designed to use as an audit tool. Dental Safety Checklists are not about creating a paper trail, they're a critical job aid to help the team (not the individual) cross check and verify, with two or more sets of eyeballs, that critpractice items haven't been missed. This cross check by multiple team members creates the needed engagement and mindfulness by the dental team during the checklist process, and is much more valuable to overall safety than having tick marks in the appropriate boxes. In fact, you should seriously consider getting rid of the tick boxes on your checklist. A check-in-the-box makes it easy to pretend something has been done when it really hasn't.

Tip 4: Include speaking parts for the team on the checklist.

Effective checklists will trigger a scripted conversation and verbal cross check of critical steps in the procedure. The more speaking parts different members of the team have, the more mindfulness and involvement you'll have in the checklist process. The reason is simple - if team members know they have speaking parts, they must pay attention to the checklist flow and be ready with their verbal responses. No one wants to be the sour note in the symphony of a well-executed checklist. No team member wants the public embarrassment of being the one who declares an item has been checked when it hasn't. The timely public declaration, in front of a team of peers, that the item you are responsible for has been checked, and is as it should be, creates a sense of responsibility and mindfulness in each member of the team that has a speaking role in the checklist.

Tip 5: Use standardized and scripted language.

Speaking parts only work if the exact language and words that should be used for each item on the checklist are crystal clear and standardized - down to the exact word or phraseology that must be used. In other words, checklist dialogue should be scripted.

Scripting will answer a number of questions.
  • Who is responsible to "call out" an item on the checklist?
  • Does this statement or "call out" require a verbal response?
  • Who should respond to "call outs," and what, exactly, should their verbal response be?
  • What should be cross-checked and confirmed before a verbal response is made?

Without an exact script to follow here, staff will create a wide variety of methods to accomplish steps in the checklist, introducing time-consuming confusion, uncertainty and frustration.

Tip 6: Design your checklist as a "read and verify" tool.

There are essentially two types of checklists in use by high reliability organizations (HROs) - Read and Do and Read and Verify. In a Read and Do checklist, the operator reads the item on the checklist and then does that step immediately after reading it. Then the next item is read and subsequently immediately accomplished. Checklists done this way are extremely time-consuming and act as giant speed bump for workflow and efficiency. This cumbersome approach to checklists will cause most surgical teams to resist using a pre-procedure checklist.

Overcome this resistance by teaching your teams to use a Read and Verify checklist system. With this method the team accomplishes critical and routine actions from working memory. They periodically pause and use the checklist to verify that the most critical actions have been accomplished. Used this way, it takes only seconds for the team to cross check and verify that nothing critical has been missed. The speed and efficiency of this method will greatly reduce the resistance you experience with implementing a checklist.

Tip 7: Use a slider board instead of a paper checklist.

Once a customized office checklist is finalized, have the checklist printed on an acrylic board with corresponding "sliders" for each item on the checklist. These sliders must be physically moved from "red" to "green" to complete the checklist. The movement of the slider must be verified by two team members from the office staff. Slider checklist boards typically contain a blank section where staff can use a dry-erase marker to make additional notes about the case or procedure.

Dental offices find these checklist slider boards more effective than paper checeklists because they:
  • Create team engagement - as attention is focused on a single place for verification of process;
  • Provide a strong visual cue to begin the cross-check process;
  • Create mindfulness and attention to detail as each team member can see an instant visual indicator of checklist completion;
  • Engage the visual senses through the use of color (green for go, red for stop);
  • Proactively eliminate error and improve efficiency; and
  • Can be mentioned in dental office marketing as a patient benefit.

Tip 8: Make it dentist-led.

In HROs such as commercial aviation, checklists are "owned" by the team leader - the captain of the crew. The captain uses the checklist to manage workflow and team performance. Checklists are one of the primary tools for supervising the team. Airline captains understand the value of checklists in creating teamwork, fostering communication, and setting expectations that team members will be vigilant and provide safety monitoring. In the case of the dental team, checklists are owned by the dentists performing the procedure. Dentists, just like airline captains, have a vested interest in ensuring checklists are used effectively and completely. As team leaders, it's their responsibility to initiate the checklist at the time of their choosing, and to insist on professional accomplishment of the checklist in its entirety.

Bonus Tip 8½: Use checklists to avoid distractions.

A recent study conducted during invasive medical procedures revealed that these fairly simple distractions caused an eight-fold increase in major medical mistakes during those surgical procedures:
  • Unexpected movement by an observer;
  • A cell phone ringing and answered by an observer;
  • An unrelated conversation between an observer and a third party;
  • Noise made by dropping a metal tray;
  • A question about a problem that came up regarding a recovering patient; and
  • A question about a residents career choice

Additionally, more than 50 percent of the physicians in the study forgot a key surgical task when these distractions were present. In comparison, only 22 percent forgot a memory task when there were no distractions. Properly constructed and used checklists create a "no interruption zone" where dentists and their staff can concentrate soley on the upcoming patient visit and ensure everything is double checked for accuracy and efficiency. These "no interruption zones" minimize distraction-induced errors and improve the safety, quality and reputation of a dental practice.

No matter where you are on your checklist journey, these 8½ tips will improve the speed of your implementation process and help you reap the patient safety rewards of a well-designed checklist system. Properly created and implemented, your dental safety checklist should offer these benefits:
  • Increase patient safety
  • Save patient lives
  • Reduce overhead costs
  • Reduce medical errors
  • Reduce medications errors
  • Improve your dental team's skills
  • Improve the performance of yourself and your teams
  • Reduce the risk of negative patient outcomes
  • Improve the level of quality, safety and reliability toward patient care
  • Increase competence and confidence for improved patient outcomes
  • Increase quality of care delivered by yourself and your team
  • Decrease mortality rates
  • Improve patient care experience
  • Improve team skills
  • Increase heightened morale of your dental team
  • Prevent distraction-induced errors
Author Bios
Cpt. Stephen Harden is Chairman and CEO of LifeWings Partners LLC and co-founder of Crew Training International, Inc. (CTI). He has helped more than 110 health-care organizations in 29 states implement the best safety practices from aviation and other high reliability industries. He is also the co-author of CRM: The Flight Plan for Lasting Change in Patient Safety, the definitive how-to text on implementing aviation-based safety tools in health care, published by HCPro. Mr. Harden has been involved in human factors and safety training for a wide variety of military and commercial customers for 21 years, producing more than 40 separate training programs. A professional pilot with 35 years of experience, he is a captain for a major international airline and a fomer U.S. Navy Top Gun instructor pilot. Stephen can be reached at sharden@saferpatients.com. His direct line is 901-413-8598. His website is www.saferpatients.com.

Dr. John B. Roberson is a full-time practicing oral and maxillofacial surgeon. Dr. Roberson performed his residency in oral and maxillofacial surgery at University Hospital at the University of Cincinnati. He served as chairman of the American Association of Oral & Maxillofacial Surgeons Residents Organization (ROAAOMS) as well as one of the founding members. He was also president of the American Student Dental Association.

Dr. Roberson has dual board certifications by the American Board of Oral & Maxillofacial Surgery and the National Dental Board of Anesthesiology. He is a member of the American Association of Oral & Maxillofacial Surgeons, Southeastern Society of Oral & Maxillofacial Surgeons, American Dental Association, American Dental Society of Anesthesiology, Mississippi Dental Association, South Mississippi Dental Association and the Mississippi Society of Oral & Maxillofacial Surgeons.

He is a former co-founder and former CEO of the Institute of Medical Emergency Preparedness (IMEP). Dr. Roberson has lectured extensively on the subject of medical emergency preparedness and training. He co-developed the Emergency Response System (ERS), which is a comprehensive medical emergency program developed for the dental profession that covers all of the six links of survival. He has authored more than 30 articles on medical emergency preparedness and has co-authored a book on medical emergencies. He has more than 15 online programs that cover different areas of emergency medicine.
Dentaltown Magazine
September 2025
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