Unforeseen Event - College of Dental Surgeons of Alberta

Step 1 of 10 - Requirements

UNFORESEEN EVENT REPORT

Unforeseen Events are events related to patient status or outcomes that are considered significant indicators of health and safety factors for patients which may or may not be associated with harm to the patient.

The following are required to report unforeseen events to the CDSA:
- Dentists who provide minimal and moderate sedation
- Dentists who provide services in accredited facilities that provide deep sedation and general anaesthesia
- Dentists who provide dental services in hospitals and AHS facilities
- Dentists who provide dental services even when no sedation is provided
General and specialty dental offices who do not provide sedation are also required to report unforeseen events to the CDSA.

In the event of an Unforeseen Event, a telephone report by the regulated member to the CDSA Registrar or their designate must be made within one (1) business day of the event occurring (780-432-1012). Please contact the current designate, Laura Dreger, Regulatory Programs Manager. If the CDSA office is closed a call must be made no later than 9 a.m. the following morning for events occurring after hours, and 9 a.m. Monday for any event occurring on a weekend.

This on-line fillable Unforeseen Event Report must be completed within two weeks of the telephone reporting to the CDSA. Handwritten reports will not be accepted.

For questions and inquiries please contact the CDSA at UER@cdsab.ca

A. Documentation Required

• The Unforeseen Event Report must be completed by the regulated member (dental practice), regulated member administering sedation in a dental practice or Accredited Non-Hospital Surgical Facility (NHSF) or Accredited Dental Surgical Facility (DSF) or regulated member who performed or was scheduled to perform the sedation and treatment, whichever may apply.

• A copy of the patient’s clinical record.

• This report completed by the regulated member involved with the case describing the unforeseen event, action taken, possible risk factors and outcome.

The College of Dental Surgeons of Alberta will review the circumstances of the Unforeseen Event with the regulated member in a dental practice or with the regulated member where sedation was administered in a dental practice and may consult with other practitioners to determine the risk of harm to patients.

The College of Dental Surgeons of Alberta and the Dental Facilities Accreditation Committee will review the circumstances of the Unforeseen Event with the Dental Operator, the Non-Owner Facility Dentist, or the accredited facility and may consult with other practitioners to determine the risk of harm to patients.

If necessary, the Registrar may suspend:

• The regulated member’s sedation registration and/or sedation permit; or

• The accreditation of any Accredited Dental Surgical Facility on a suspicion of continuing risk.
B. Mandatory Notification
Indicate Location of Unforeseen Event*
- Dental Practice that does not provide sedation services
- Minimal and Moderate Sedation in a Non-Hospital Dental Practice
- Deep Sedation and General Anaesthesia in a Non-Hospital Dental Practice
- Dentists working in hospitals or AHS facilities
Please Indicate Facility Type*
- Non-Hospital Surgical Facility (NHSF)
- Dental Surgical Facility (DSF)

3. General Information
Dental Practice Name*
Name of dental practice where the event occurred.
Hospital or AHS Facility Name*
Name of hospital or AHS facility where the event occurred.
Dental Practice Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Hospital Name*
Please Specify*
Non-Hospital Dental Surgical Facility (NHSF) Name*
Dental Surgical Facility (DSF) Name*
Please Specify*
Medical Director Name*
Prefix First Last
Dental Operator (Anaesthesia Provided By)*
Prefix First Last
General Anaestheologist Name (Anaesthesia Provided By)
Prefix First Last
Oral & Maxillofacial Surgeon Name (Anaesthesia Provided By)
Prefix First Last
Regulated Member Name (Treatment Procedure Provided By)*
Prefix First Last
Date of Unforeseen Event*
YYYY dash MM dash DD
Date of Procedure*
YYYY dash MM dash DD

10. Certification

I hereby confirm that I have reviewed the contents of this report and certify that the information herein is true and accurate.
Regulated Member Who Performed Treatment
Name*
First Last
Submission Date*
MM slash DD slash YYYY
Consent*
By submitting this registration electronically, I acknowledge and agree that the contents are true and complete as if I had signed the documents in writing. I declare that the contents of this registration are true and complete and I understand and agree that if I make a false or misleading statement or representation in my registration, I will be deemed to not have satisfied the requirements of registration. I further understand and agree that making a false or misleading statement to the College of Dental Surgeons of Alberta may constitute unprofessional conduct.
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Submit Date*
DD dash MM dash YYYY
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Submit Time*

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