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The aim of this study was to investigate cases of accidental ingestion or aspiration occurring at Tokyo Dental College Chiba Hospital over the last 4 years in order to determine how the incidence of such events could be reduced. Forty cases of accidents occurring at our hospital over a 4-year period commencing in 2008 (representing 27% of the total number of accidents) included accidental ingestion in 39 patients and aspiration in one. Most of these accidents occurred during the removal or placement of restorations or prosthetics, and the ingested objects were mostly crowns and inlays. Accidental ingestion or aspiration occurred more frequently in the right molar region and when procedures were conducted by practitioners with less than 1 to 7 years of experience, and especially 1 to 3 years only. A higher rate of such accidents was observed in male patients in their 50s to 70s. The conventional safety procedures developed by the Medical Risk Management Team should be adhered to wherever possible. Furthermore, we propose the following measures based on the present results: accident prevention training for students and clinical trainees; improvement of the in-hospital manual; personal coaching for those breaching the guidelines of the safety manual; and raising awareness of the need for greater care in preventing incidents of accidental ingestion or aspiration at the Tokyo Dental College Chiba Hospital.

The occurrence of accidental ingestion/aspiration and preventive measures were investigated at Tokyo Dental College Chiba Hospital. In addition, the characteristics of accidents at our hospital were analyzed by surveying the awareness of accidental ingestion/aspiration to utilize the data for prevention. Accidental ingestion accounted for about 30% of accidents that occurred at our hospital in fiscal 2008, but all ingested items were naturally excreted, and no accidental aspiration occurred. Accidental ingestion most frequently occurred when dental restorations were removed. Inlays and crowns were most frequently ingested, and dentists with 5 to less than 10 years of clinical experience tended to be involved in these accidents. According to the results of the questionnaire, removal of restorations was perceived as the treatment least likely to cause accidental ingestion/aspiration. Moreover, dentists who always took preventive measures against accidental ingestion/aspiration accounted for only 40% or less on average. To avoid accidental ingestion/aspiration, repeated courses and individual instruction for repeaters and the establishment of a surveillance system along with manuals to manage the violation should be emphasized.