Article

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Learning from mistakes – students’ learning experiences fromclinical adverse events.
Hiroshi Ishikawa 1,2, Layra Valdes3, Juanna Xie3, Sang J Lee3, Hiroe Ohyama3, Masahiko Maeno 1, Isabel Tate3,
Takahiko Shiba2, Hawazin Elani 4, Shigemi Nagai 3

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1. Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA,USA.
2. Department of Department of Adhesive Dentistry, School of Life Dentistry at Tokyo, The Nippon Dental
University, Tokyo, Japan.
3. Department of Restorative Dentistry and Biomaterial Sciences, Harvard School of Dental Medicine, Boston,
MA, USA4. Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA,
USA* Correspondence: shigemi_nagai@hsdm.harvard.edu Tel:+1 (617) 432-2928

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Abstract: Clinical training in the teaching practice is essential for developing patient-specific skills,
yet the transition from preclinical to clinical training presents significant challenges for students.
This study seeks to enhance clinical training quality by retrospectively examining adverse events
reported by third-year pre-doctoral students from classes 202A, 202B, and 202C during their firstten months of clinical practice at the teaching practice. A total of 235 adverse events were reported
across eight disciplines: Treatment planning (TP), Operative (OP), Periodontics (PER), Endodontics(EN), Oral Surgery (OS), Fixed Prosthodontics (FP), Removable Prosthodontics (RP), and PatientManagement (PM). Case discussions followed, focusing on problem-solving and prevention. The
distribution of events was as follows: TP (11.5%), OP (17.7%), PER (13.1%), EN (6.9%), OS (6.2%), FP(24.2%), RP (5.0%), and PM (15.4%), with FP, OP and PM experiencing the highest rates of adverse
events. Across these disciplines, inadequate clinical skill proficiency was identified as a primarycause of adverse events. Other contributing issues included miscommunication, insufficient explanations to patients, a lack of administrative support, case complexity, and a deficit in diagnostic
examinations and skills. The study highlights the prevalence of adverse event, suggesting that abetter understanding of these incidences can improve student performance and patient outcomes,
and reinforces the need to include such analyses in dental education.

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Keywords: Learning from mistakes, Clinical teaching, Adverse event, Teaching practice, Dental education, Learning environment.

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Academic Editor: Firstname Lastname
Received: date
Revised: date
Accepted: datePublished: date

Copyright: © 2024 by the authors.
Submitted for possible open accesspublication under the terms andconditions of the Creative Commons
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license(https://creativecommons.org/licenses/by/4.0/).

1. Introduction
A humanistic and professional learning approach is critical in clinical education indental schools. Dental educators are responsible for ensuring a learning experience in a
productive and safe learning environment [1-3]. There is consensus in the dental education literature that student perceptions of the curriculum should be given serious consideration in all discussions and decisions relating to their education. [4-7]. One study
indicated that students’ learning environment perception deteriorates throughout the
curriculum, especially within the preclinical training to clinical training transition [2].
Clinical training involves direct patient care, offering a unique and specific learning experience in contrast to preclinical training, which is practice-oriented and designed to prepare students for the realities of the clinical environment.
The Harvard School of Dental Medicine (HSDM) introduced an interdisciplinary
course curriculum in 1990, which emphasized comprehensive treatment planning and

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2 of 11clinical care [8]. The goal of this curricular change was to assess the extent of comprehensive care delivered and to confirm that continuity of care was being maintained throughthe completion of comprehensive treatment plans [9-11]. In 2009, HSDM developed andimplemented a case completion curriculum within the reformed predoctoral curriculum,
which replaced the traditional model based on procedural numerical requirements [12].
The redesign of the clinical component aimed to facilitate a patient-based comprehensive
care experience within the student teaching practice [13,14]. An analysis of five years ofretrospective data, along with a survey of student perspectives, indicated that the casecompletion clinical curriculum – with its priority on comprehensive patient management– has enhanced patient-based care [15]. Further assessment revealed that the new curriculum not only encouraged students to deliver comprehensive care but also fostered agreater commitment to the completion of treatment plans. There have been fewer patienttransfers between students and an improved transition of care upon graduation. Moreover, this clinical education model has been instrumental in teaching student’s patient management skills that are beneficial as they embark on their professional practice [16]. Thesestudies offer further evidence supporting the value of a comprehensive care model in clinical education. Nevertheless, the transition from the pre-clinical phase to the clinical training phase still presents numerous challenges for students. Despite the systematic andstructured support provided by dental schools for both students and faculty during thistransitional phase, adverse events still occur. Students may experience nervousness andstress on their first day of performing clinical procedures. Additionally, patient management is a skill typically acquired through experience and is challenging to impart in a
preclinical setting.
The definition of an adverse event varies. The National Health Service (NHS) definesa patient safety incident as ‘any unintended or unexpected incident which could have or
did lead to harm for one or more patients receiving NHS-funded healthcare’, thereby including incidents that result in no harm and near misses [17]. In contrast, the Harvard
Medical Practice Study’s methodology used in retrospective chart review studies in several countries considers adverse events to be injuries that result in prolonged hospitalization, disability, or death, which are caused by healthcare management including incidents
with more severe consequences [18]. These large international reviews of patient charts
estimate that between 4% and 17% of hospital admissions are associated with an adverse
event and a significant proportion of these (one- to two-thirds) are preventable [8-28].
In dental clinical education, knowledge about adverse events is limited. These events
could be better managed if students and supervising faculty understood their causes andpotential solutions. In Advanced Dentistry, one of the seven multidisciplinary preclinicalcourses at HSDM, students discuss cases they have encountered. They identify and reflect
on adverse events experienced during teaching practice. By discussing the event, its
causes, and effective prevention methods, students can learn from each other’s experiences. Investigation adverse events sheds light on their incidence and highlights areas
where risk can be mitigated, and prevention strategies can be implemented.
The aim of this study was to assess the adverse events that occurred at HSDM's teaching practice during the first ten months of the students' clinical training, by analyzing datafrom the Advanced Dentistry course that is held at the ten-month mark of their clinicaleducation. This study aimed to analyze the frequency and characteristics of adverse
events and propose preventive measures for both students and faculty to prevent theirrecurrence, thereby enhancing the quality of future preclinical education.

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2. Materials and Methods
The Advanced Dentistry (AD) course, placed at the end of third-year dental curriculum at HSDM, requires to present a comprehensive review of three to four clinical adverse
events they have experienced in the last 10 months since starting clinical procedures at
the teaching practice. Each event presentation covers the adverse event that occurred, its
resolution, strategies for prevention, and a literature review of their specific adverse event.

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The incidents are also categorized into one of the following disciplines: Treatment planning (TP), Operative (OP), Periodontics (PER), Endodontics (EN), Oral Surgery (OS),Fixed Prosthodontics (FP), Removable Prosthodontics (RP), and Patient Management(PM). This retrospective study analyzed presentations from third year predoctoral students across three cohorts (classes of 202A, 202B, and 202C) at the Harvard School of Dental Medicine. All adverse events reported were examined in terms of the event frequency,
discipline-specific characteristics and potential future preventive measures. This study
was approved by the IRB of Harvard Faculty of Medicine (IRB22-1231).

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3. Results

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In total, 279 adverse events were analyzed. Among the 279 events, 24.4% of eventswere in FP, 17.6% in OP, 15.4% in PM, 12.9% in PER, and 11.8% in TP. The disciplines of
EN, OS, and RP accounted for less than 10% each (Figure 1). Looking into the frequencyof adverse events across three classes (Figure 2), the distribution pattern within the disciplines was consistent, and no statistical difference was observed as determined by the chisquare test (p=0.2299, chi-square=17.512).

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Figure 1. Incidence of Adverse Events in Dental Disciplines.
Percentage of adverse events reported in each dental discipline by third year predoctoral students
from 3 classes. The adverse events were divided as follows: 24.4% in Fixed Prosthodontics (FP),
17.6% in Operative (OP), 15.4% in Practice Management (PM), 12.9% in Periodontics (PER), 11.8%
in Treatment Planning (TP), 6.8% in Endodontics (EN), 6.1% in Oral Surgery (OS), and 5.0% in Removable Prosthodontics (RP).

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Figure 2. Distribution of adverse events by discipline across all three class years at HSDM.
The most frequently occurring adverse events across the three classes were in the disciplines of
Fixed Prosthodontics (FP), Operative (OP), Practice Management (PM) and Treatment Planning
(TP).

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The causes of adverse events are detailed in Table 1 and illustrated in Figure 3. Table
1 describes the common areas of events that occur within each discipline and categorizes
the various types of causes. Adverse events are caused by a variety of sources, including
clinical errors, management mistakes, and administrative oversights, among others. Clinical proficiency was identified as the primary contributor across disciplines, with miscommunication, language barriers, inadequate patient explanations, and complex cases also
contributing significantly.

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Table 1. Common areas of adverse events and categorized causes.

Discipline

Common Areas of Adverse Events

CausesFP

Provisional crown.
Tooth preparation.
Impression.
Damage to adjacent teeth/tissue.
Poor quality of crown.
Lab-related issues.

Poor clinical proficiency in fabricating provisional crown.
Poor clinical proficiency in tooth preparation.
Poor clinical proficiency in capturing bite registrations.
Poor clinical proficiency in material use/instrument control
Poor clinical proficiency in obtaining proper moisture control.
Inaccurate shade selection.
Miscommunication with dental laboratory.

OP

Quality of fillings.
Post-operative pain.
Damage to other tissue.

Poor clinical proficiency in composite restoration techniques.
Poor clinical proficiency in material use/instrument control.
Insufficient explanation to patients.

PM

Cancellation of appointment.
Treatment costs.
Insurance coverage.

Miscommunication (language barrier).
Poor patient communication.
Lack of administrative support.

PER

Surgical procedure.
Treatment costs.
Damage to other tissue.

Poor clinical proficiency in perio surgery.
Poor procedural preparation.
Lack of administrative support.
Case complexity.

TP

Diagnosis.
Treatment plan comprehension.

Deficient skills in diagnostic examinations.
Miscommunication (language barrier).
Case complexity

EN

Obturation.
Diagnosis.
Post-operative pain.
Restorative work delays.

Poor clinical techniques.
Deficient skills in diagnostic examinations.
Miscommunication (language barrier).
Poor patient communication.

OS

Extraction.
Anesthesia.
Damage to adjacent tissue/teeth.

Poor clinical proficiency in anesthesia techniques
Poor clinical proficiency in extraction techniques.
Poor clinical proficiency in surgical procedures.

RP

Occlusion.
Post-operative pain.
Integrity of dentures.
Scheduling issues.

Poor clinical proficiency in capturing bite registrations.
Poor clinical proficiency in taking impressions.
Poor clinical proficiency in adjustment procedures.
Miscommunication (language barrier).

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Figure 3 describes the frequency of causes for adverse events in each discipline. Poor
clinical skill proficiencies were the major cause across all five clinical disciplines. In FP,
the biggest clinical challenge involved managing provisional crowns, which accounted
for 30.9% of adverse events, followed by tooth preparation (14.7%), bite registration(14.7%), tissue management (13.2%), shade matching (7.4%) and impression taking (5.9%),
with lab-related miscommunications comprising 13.2%. In OP, clinical inadequacies infilling quality, particularly with resin composite restorations, were the leading cause. Adverse events in EN, OS, and RP primarily involved clinical complications with obturation,
anesthesia, extraction, protection of adjacent teeth/tissue, denture bite registration, andprosthesis adjustment. Additionally, EN saw 26.3% of events arising from diagnostic

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5 of 11errors. Poor clinical skill proficiencies in PER accounted for 58.2% of issues, including periodontics’ surgical techniques (16.7%) and procedure preparation (36.1%), while difficulties with patient communication accounted for 33%. In TP, the most common cause wasdiagnostic errors due to a lack of clinical and administrative information, such as up-todate radiographs and insurance details. Interestingly, case complexity was indicated for
PER and TP. PM was mostly affected by continuous cancellations, with miscommunication and language barriers identified as significant contributing factors (48.8%).
Looking into the frequency of causes across the three classes, a significant difference
was observed in the disciplines of TP, PM, PER, EN, and RP (p<0.01). However, no significant difference was noted in OP, FP and OS (Figure 4).

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Figure 3. Frequency of Causes for Adverse Events by Dental Discipline.
The total frequency of poor clinical proficiency was calculated 86.8% in FP, 83.7% in OP, 52.8% in PER, 47.4%
in EN, 100% in OS, and 85.7% in RP. Miscommunication was notable in 5 disciplines; TP, PM, FP, EN and RP.

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Figure 4. Cause Comparison of Adverse Events Between All Cohorts.
Each individual graph represents a particular discipline and illustrates the frequency of causes across all
three classes. There was no significant difference observed in the clinical disciplines of OP, FP and OS.

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4. Discussion
Aim and importance of learning from mistakes
The study aims to analyze adverse event data to understand patterns and help develop preventive strategies that can aid both students and faculty in reducing recurrences
and improving the quality of preclinical dental education.
Students in the AD course were asked to share three to four significant adverse
events they experienced during their clinical training, with the only requirement beingthat each event fall within a recognized dentistry discipline. These events varied in termsof their severity and the impact on both patients and students. The nature of the mistakes
shared ranged from minor, with negligible consequences, to major, with larger implications. Traditionally, research has suggested that students often learn more effectively fromserious mistakes due to the strong emotional impact associated with the experience [29].
Indeed, the likelihood of repeating an error decreases when the consequences are substantial, as the experience tends to leave a lasting impression. The aim of integrating a ‘learning from mistakes’ session in the AD course is to collectively, as a class, comprehend thereasons behind which these adverse events occurred, and to ultimately reduce the incidence of such events occurring in the future within the predoctoral education.
Analyzing the Frequency and Causes of Adverse Events Across Clinical Disciplines
Complications in FP and OP, along with challenges in PM, were common across allclasses. FP experienced the highest rate of adverse events (24.4%), followed by OP (17.6%).
This pattern may reflect the higher demands for OP and FP procedures within the patient
population at the HSDM teaching practice. In contrast, PER (12.9%), EN (6.8%), and OS(6.1%) reported fewer complications. This could be partly because the more complex casesin these disciplines are often assigned to residents and faculty, leaving pre-doctoral students with less challenging tasks. Additionally, while pain is more commonly experienced
in invasive fields like OS and PER, it becomes notably more significant when it occurs in
OP and EN procedures, where it is less expected.
The adverse events encountered within each discipline result from various factors.
In OP, incidences are linked to students’ inexperience with treating real teeth. The thirdyear marks the first-time students work on real teeth, which contrast with the plastic models used in pre-clinical training. At HSDM, once third year students pass the operative
course’s preclinical summative, they can immediately begin procedures on patients. Thistransition presents new hurdles, such as managing patient behavior and expectations,achieving proper isolation, navigating time constraints, and satisfying faculty standards.
In Fixed Prosthodontics (FP), the most common complication was provisional
crowns dislodging or breaking within a day or two of placement (30.9%). Students recognized these adverse events were frequently due to inadequate moisture control during
cementation, improper tooth preparation including excessive taper, insufficient occlusal
reduction, and inadequate height of the remaining clinical crown. Such problems reflect aneed for more clinical practice and experience.
In Periodontics (PER) student inexperience, particularly with first-time clinical use
of periodontal instruments (36.1%) in conjunction with inadequate procedural preparation, often led to adverse events. Other unanticipated challenges, such as damage to restorations (16.7%), which are not covered in pre-clinical training, further complicate realworld practice.
In Endodontics (EN), common complications included underfilling, overfilling, perforation, and case misdiagnosis. Incorrect filling often stemmed from poor gutta percha
measurements. Lack of experience with radiograph interpretation and diagnostic tests often led to misdiagnoses, with miscommunication delaying restorations and, in severe instances, necessitating root canal retreatment.

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Mistakes in Oral Surgery (OS) often stemmed from inexperience and insufficient
clinical knowledge, leading to adverse events of ineffective anesthesia, extraction complications, and damage to adjacent teeth and tissues. The lack of pre-clinical OS practicemeant students faced these procedures for the first time on real patients. While OS rotations take place during third and fourth years at HSDM, introducing clinical rotations
earlier, in the second year, could be crucial for skill development.
In Removable Prosthodontics (RP), adverse events often arose from errors in taking
bite registrations during the articulation processes. Accurate bite registrations are crucial
yet one of the most challenging tasks in RP. Thus, identifying errors early is essential, as
the success of all subsequent procedures depends on the precision of these initial measurements. Moreover, RP, as a field involves detailed lab work at every step. Meticulous
attention to detail must be developed during early dental training to ensure high-quality
outcomes throughout.
Patient Management (PM) and Treatment Planning (TP) are two major non-clinicalareas prone to adverse events. PM issues often stem from poor provider-patient communication, scheduling conflicts, insufficient follow-ups, and unmet patient expectations.
These errors underscore the challenge students face when transitioning from theoreticallearning to practical, hands-on patient care. In recent years, the HSDM Teaching Practicehas experienced an increase in non-English speaking patients, and while translation services via iPads are available, they frequently fall short due to audio problems and ineffective communication among provider, translator, and patient. The communication barriers
can lead to misunderstandings, repeated cancellations, treatment postponement, and insome cases, teeth becoming non-restorable. Additionally, conversation about treatment
costs are sensitive; varied insurance coverages necessitate increased administrative support for students to allow them to focus more on patient care.
In TP, errors often stem from difficulties in obtaining comprehensive diagnostic data,such as models, x-rays and consultations. Without precise diagnostics, creating an appropriate treatment plan is challenging. Additionally, insufficient patient information, suchas chief complaint, goal and limitations can lead to misguided treatment plans. Miscommunications between students and patients due to unclear treatment planning principles
or language barriers further complicate the process.
In general, performing procedures on patients for the first time is challenging forevery dental provider. There are difficulties that arise in the clinical setting that cannot be
trained for in pre-clinic. For example, accounting for patient emotions, which vary greatly
in a dental setting, is impossible in a simulated environment. It is therefore unsurprisingthat issues with patient management rank as the third most common challenge in clinic.
Increased interaction with patients helps students navigate these challenges.
The Importance of Analyzing Mistakes
Understanding errors is crucial to the learning process and offers valuable lessons tostudents. Despite understanding this, there’s often reluctance to discuss mistakes due tofear of judgement or repercussions. Dentistry is a field of lifelong learning, and embracing
mistakes is a part of growth. For example, morbidity and mortality conferences in the
medical field serves as a model. These conferences provide a secure space for physicians
to discuss mistakes confidentially and constructively within a peer-protected environment [30]. Such open discussions are vital for self-reflection and encourage better future
practices. In dental education, these discussions help students take responsibility, promote transparency, and maintain accountability, all of which are essential for learning.
While there may be concerns about criticism or peer perception, openly addressing errors
fosters a culture focused on learning and leads to deeper reflection and the developmentof more effective strategies for future practice.

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Introducing the practice of acknowledging mistakes early in dental education is crucial, because it encourages students to adopt a habit of transparency with patients
throughout their career. Dentists have an ethical responsibility to honor patient autonomy,necessitating transparency, particularly when errors affect a patient’s health. Open disclosure, as taught in the Advanced Dentistry course, promotes a culture of transparency anddeters concealment of mistakes from patients, a practice that could undermine trust in thedental profession. Therefore, it is imperative for dentists to be upfront with patients about
any mistakes impacting patient health.
The transition from preclinical training to clinical practice is one of the most challenging times of a student’s dental education. Students not only shoulder the responsibility of patient care but also juggle various other obligations. Amidst this high-stress environment, creating a supportive learning atmosphere can alleviate fear and encourage
open discussions and reflections on mistakes. While some students excel under stress,
others may benefit from calmer, “safer” spaces that are more conducive to sharing, suchas the ones provided by group discussions in the AD course. In fact, studies using functional magnetic resonance imaging have found that the brain’s reward-memory loop is
more active during success, suggesting that achievements could have a stronger influenceon learning than failures [31].
Ultimately, understanding the factors that drive both successes and failures is crucial.
Examining the causes behind different outcomes enables students a deeper understanding. Educational programs should therefore incorporate discussions about both successes
and failures into the curricula. It may also be advantageous to specifically discuss the factors contributing to successful procedures. That way, students are given the chance tounderstand the full spectrum of the clinical experience.
Future study
In the future, it’s important to continue investigating whether a school is meeting its
aims of transitioning pre-clinical students to clinical practice. Specifically, a longitudinalapproach, such as conducting a five-year follow-up study to assess whether there has beena measurable improvement in the occurrence of adverse events would be helpful. However, it’s clear that not all issues in dental education have been resolved, and ongoing
research is needed to address these persistent challenges. By continuing to update current
educational methods and provide safe environments for students to discuss their challenges and successes, dental education can work towards improving patient care and clinical training continuously.

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5. Conclusions
Our findings indicate that adverse events in the clinical setting are common. Understanding common adverse events prior to the clinical procedure would be helpful forstudents to perform better. Students should prepare as much as possible prior to practicing procedures in the clinical setting and be aware of common causes of adverse events.
Educators should also be aware of the difficulties that unexperienced student clinicians
face. Knowledge of common errors can help facilitate success in challenging and stressful clinical situations.

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Supplementary Materials: N/A

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Author Contributions: Conceptualization, H.I., H.E., M.M. and S.N.; methodology, H.I., H.E. and
S.N.; validation, L.V., J.X., H.O., M.M., I.T. and S.N.; formal analysis, H.I, L.V., J.X., I.T. and S.N.;
investigation, H.I, H.O., S.L. and S.N.; resources, H.E. and S.N.; data curation, H.I., I.T. and S.N.;
writing—original draft preparation, H.I., I.T., L.V., J.X. and S.N.; writing—review and editing, S.L.,
H.O., and S.N.; visualization, S.L., H.O., and S.N.; supervision, S.N.; All authors have read andagreed to the published version of the manuscript

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Funding: This research received no external funding

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Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Harvard Faculty of Medicine(IRB22-1231, October 3, 2022).

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Informed Consent Statement: N/A

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Data Availability Statement: We encourage all authors of articles published in MDPI journals toshare their research data. In this section, please provide details regarding where data supporting
reported results can be found, including links to publicly archived datasets analyzed or generated
during the study. Where no new data were created, or where data is unavailable due to privacy or
ethical restrictions, a statement is still required. Suggested Data Availability Statements are available in section “MDPI Research Data Policies” at https://www.mdpi.com/ethics.

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Acknowledgments: N/A

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Conflicts of Interest: The authors declare no conflicts of interest.

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