Open Wide Learning Lab (OWLL): Improving Patient Safety in Dentistry

Principal Investigator: Muhammad Walji, Ph.D., University of Texas Health Science Center at Houston, Houston, TX 
AHRQ Grant No.: HS027268 
Project Period: 09/09/19-08/31/24 
Description: OWLL aimed to improve patient safety in dental settings by establishing a learning health system that used adverse event (AE) data to identify safety risks and test targeted interventions. Focusing on pediatric dental sedation, the project was implemented at two large academic dental institutions and guided by systems engineering and human-centered design principles.

The specific aims were to:¹

1. Identify and understand the contributing factors behind common dental AEs.
2. Design and develop targeted interventions using a human-centered design approach.
3. Implement and evaluate the interventions across diverse clinical settings.

Researchers used a mixed-methods approach that included safety culture surveys, root cause analysis, ethnographic observations, and provider and patient interviews. EHR-based trigger tools were employed to identify over 4,000 dental records that potentially contained AEs.² These triggers showed significantly higher detection rates than random chart reviews, with positive predictive values ranging from 0.09 to 0.23. Root cause analysis of 59 selected charts found that 75 percent of AEs were preventable or probably preventable, often due to training deficiencies, inadequate supervision, and patient noncompliance.³

OWLL developed and tested three interventions:

• A parent-facing pamphlet explaining what to expect during pediatric dental sedation.
• A child-friendly educational video that simulated a sedation visit.
• Enhanced digital sedation forms that documented preoperative, intraoperative, and postoperative details within the EHR.

These interventions were developed and refined through human-centered design activities and piloted using a minimum viable product approach.² All three interventions were later implemented in 81 pediatric dental sedation procedures across both sites and were met with high compliance.⁴ For example, the intra-operative sedation form achieved 100 percent completion at both sites, and airway assessment documentation reached 100 percent compliance at one site. Provider adherence to using the pamphlet with families exceeded 75 percent.

Surveys and focus groups showed that providers viewed the interventions as helpful, with 71 percent at Site 1 and 93 percent at Site 2 reporting that the interventions would be a welcome part of regular practice. Parents appreciated the clear communication and ease of understanding provided by the pamphlet and video, which helped reduce anxiety and improve preparation for sedation procedures.

The OWLL team’s work highlights the value of engaging patients, families, and providers in safety innovation and underscores the importance of human-centered design in dental care. The project created a replicable model for quality improvement that could be adopted by other dental clinics, advancing the field of dental patient safety and supporting AHRQ’s goals for safer, more effective care.¹

To date, this PSLL’s work has resulted in at least six peer-reviewed publications, five citations in other publications, and several national presentations.

Publications

2025

• Zouaidi K, et al. Design and development of an intervention to improve the quality and safety of pediatric dental sedation: A human-centered design approach. J Patient Saf 2025 – Special Issue. In press.

2023

• Gandhi HA, et al. Assessing the safety of deep sedation in outpatient pediatric oral health care. J Am Dent Assoc 2023;154(11):975-983.e1.
• Kalenderian E, et al. Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis. J Patient Saf 2023;19(5):305-312.
• Kalenderian E, et al. Learning from data in dentistry: Summary of the third annual OpenWide conference. Learn Health Syst 2023;8(2):e10398.

2022

• Zouaidi K, et al. An observational retrospective study of adverse events and behavioral outcomes during pediatric dental sedation. Pediatr Dent 2022;44(3):174-180.

2021

• Walji M, Kalenderian E. Avoiding errors in dental practice. Qual Resour Guide 2021.

References

1. Walji M. Final Report: Open Wide Learning Lab (OWLL): Improving Patient Safety in Dentistry. 2024, University of Texas: Houston, Texas.
2. Kalenderian E, et al. Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis. J Patient Saf 2023;19(5):305-312.
3. Zouaidi K, et al. An observational retrospective study of adverse events and behavioral outcomes during pediatric dental sedation. Pediatr Dent 2022;44(3):174-180.
4. Gandhi HA, et al. Assessing the safety of deep sedation in outpatient pediatric oral health care. J Am Dent Assoc 2023;154(11):975-983.e1.