NHS Improvement defines ‘never events’ as ‘patient safety incidents that are wholly preventable where guidance of safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers’.1 Never events in dentistry have previously included wrong site local anaesthetic administration and wrong site tooth extraction. A total of 155 wrong site tooth extractions, carried out in both primary and secondary care, were reported in England between 2015 and 2019, accounting for approximately 20% of all wrong site surgery never events and 8% of the total never events during that time period.2 Wrong site tooth extraction has recently been removed from the list of never events. This article discusses the reasoning behind this, and explores the associated implications and recommendations for dental professionals.
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