Optimizing digital documentation of invasive oral surgery procedures to improve patient safety: a quality improvement project at a dental centre

Background: Incomplete documentation of invasive oral and maxillofacial surgery (OMFS) procedures compromises patient safety and continuity of care, and jeopardizes compliance with International Patient Safety Goal (IPSG) 4, which mandates 100% adherence to safe-surgery documentation. Baseline audits revealed documentation completeness as low as 7-22%. Methods: A multidisciplinary QI project was conducted at the OMFS outpatient clinic of Prince Sultan Military Medical City, Riyadh, from August 2023 to August 2024. The Model for Improvement was applied through iterative Plan-Do-Study-Act (PDSA) cycles, with root-cause analysis using fishbone and Pareto diagrams. Interventions included structured education and reorientation, audit-and-feedback, extended documentation time, a blended auto-populated electronic form in the R4 dental software, and monthly revision of incomplete records. Results: At baseline (August-September 2023), completeness was 7-22%. After educational and feedback interventions, compliance rose to 53-67%, then declined to ~53% (January-March 2024). Following workflow redesign and system-level changes, it increased steadily, reaching 97% by August 2024 (overall median 62%). Component-level gains included a 61% increase in invasive procedure record completion, 58-59% in site marking, and 30% in informed consent documentation. Conclusions: A structured, multicomponent QI intervention markedly improved digital documentation of invasive OMFS procedures, aligning practice with IPSG4 and strengthening patient safety. Combining system-level redesign with education, feedback, and routine auditing produced sustainable gains and offers a transferable model for other dental and surgical services.