Haste, Pressure and Staffing Shortages Contribute to Costly Mistakes

The origins of penicillin are said to have begun with an oversight: Alexander Fleming forgot to clean the dirty dishes in his lab sink before leaving on vacation. Upon his return, he noticed a petri dish of staphylococci had grown a mold that wiped out the sample around it, a discovery that eventually led to the life-saving antibiotic.

Unfortunately, most oversights do not have such laudable outcomes. In dentistry, there is potential for error, such as mistaken identity or treatment performed on the wrong tooth. Some of these matters can be addressed and resolved quickly to everyone’s satisfaction, but others result in costly professional liability claims.

The Dentists Insurance Company’s Risk Management Advice Line fields calls each day from dentists facing practice challenges. Recently, Risk Management analysts have noticed an increase in calls with concerns about the wrong treatment being performed.

Case Study 1

A patient was referred to an endodontist for endodontic treatment of tooth No. 13. After initial treatment, the patient remained symptomatic for a while. The endodontist recommended an apicoectomy due to the patient’s persistent symptoms. The patient opted to postpone further treatment on the tooth due to financial constraints. Ultimately, the patient decided to have the tooth extracted rather than undergo any further attempts to save it with an apicoectomy. The endodontist referred the patient to an oral surgeon for the procedure.

The patient presented to the oral surgeon’s office without a referral slip. The office contacted the general dentist’s office and requested that they provide a referral slip for their records. Under pressure to provide the referral urgently, the office manager only referred to the patient’s radiographs, which revealed gross decay on tooth No.14, and not the treatment notes. She therefore assumed that tooth No.14 was the intended tooth and provided a referral slip for the oral surgeon recommending the removal of tooth No. 14.

The patient called the general dentist the following day, reporting that the wrong tooth had been extracted. Tooth No. 13 had been causing more discomfort than tooth No. 14, and she believed she could postpone treatment of tooth No. 14 until it was causing more pain. She did not want to invest additional money for further treatment. The patient was understandably upset and demanded that the dentist pay for the removal of tooth No. 13.

The referring dentist contacted TDIC’s Advice Line, expressing concern and seeking guidance on how to discuss the matter with the patient. The analyst recommended having the patient come into the office for a face-to-face conversation with the dentist rather than attempting to address the matter through a phone call. The dentist could then acknowledge what had occurred, apologize for the error and discuss workable solutions. The analyst further advised the dentist that he should be prepared to address the patient’s questions about fees associated with the necessary treatment along with the amounts the dentist planned to cover for treatment that the patient would receive at no cost. The patient was cooperative because she understood that tooth No. 13 was already in need of extraction, and tooth No. 14 had a questionable prognosis due to the amount of decay.

This situation ultimately reached a favorable and mutually agreeable resolution. However, if the dentist had not developed a plan and clearly communicated with the patient on how he would address the matter, this could have become a claim, escalated to the patient demanding a larger settlement or even a dental board complaint due to the hurried and unfortunate action taken by the office manager. Advice Line analysts recommend that the dentist, rather than other dental team members, complete the referral slips before allowing staff to forward these to the referring dentist or providing the referral slip to the patient.

Case Study 2

Another Advice Line call involved the treatment of two young siblings, 5-year-old Braxton and 3-year-old Evan. These patients were accompanied to an appointment by their nanny. When staff proceeded to seat the first patient, they understood that they were seating “Evan” and asked the nanny to confirm that in fact the patient’s name was Evan. The nanny affirmed twice that yes, they were seating Evan.

Despite there being a language barrier when communicating with the nanny, she appeared to understand what the staff was asking. The dental team assumed, based on the nanny’s responses, that the patient information and chart for the patient they seated was Evan. As they were preparing to administer the patient nitrous oxide, a team member who had been present at the siblings’ initial visit caught the error and informed the other staff that the seated patient was Braxton, not Evan. The team was relieved to have caught the mix-up just in time before treatment began.

The dentist called the boys’ parents and was able to speak with their father, who seemed calm and expressed that he understood how this could occur. He then handed the telephone to their mother, who was less calm. She became irate and demanded to know how the office could be so careless and confuse the two siblings who were two years apart in age and demanded a written response.

The dentist called the Risk Management Advice Line for guidance on how to continue the conversation with the parents in a more positive and productive manner as the call with the mother ended abruptly. The analyst advised the dentist to write an email to the parents acknowledging the error and outlining what occurred and what measures she and her team implemented to prevent it from occurring again. The dentist was advised to also acknowledge that the family may choose to establish care elsewhere and to offer to speak with them further in person if they desired.

Unfortunately, even with careful planning, mistaken identity does occasionally occur in dental practices, resulting in treatment of the wrong patient. The Advice Line has received similar calls where a dentist has reviewed the chart and radiographs from one sibling, then treated another child in the same family after relying upon the wrong chart and treatment plan. It also happens to unrelated adults who share a common name.

How do treatment mistakes happen?

Identity or treatment plan mistakes can occur in any dental practice. While there are a variety of factors that can contribute to mix-ups, research by TDIC’s analysts reveals the most commonly occurring elements. Being aware of these factors can help your practice team develop a proactive approach for prevention.

• Errors on referral slips. The most common cause for treatment mistakes is writing the wrong tooth number on referral slips. Allowing staff to fill out the referral forms without getting the treating dentist’s confirmation of accuracy and signature is typically what leads to misinformation.
• Performance or production pressure. Often, a dentist who is in a rush trusts their dental assistant to display the correct radiographs and treatment plan for the patient they are treating, failing to verify that the diagnostic displays are the most current or correctly matched to the patient. Scheduling adequate treatment time for cases, paying attention to detail and observing a timeout before treatment can eliminate the temptation to take shortcuts. Learn more about the risks of shortcuts and how to safeguard your practice against them in TDIC’s recent Risk Management publication.
• Staffing shortages. Frequently, performance and production pressures can be blamed on an undertrained or understaffed practice team. Having qualified, reliable staff makes a substantial difference to how the office runs and the level of patient care a practice can provide. Without a well-staffed office able to follow patient care protocols, things can – and will – slip through the cracks. TDIC recommends protecting your practice and professional reputation by implementing effective processes to find and hire solid employees.

A proactive approach to prevention

Preventing treatment mistakes begins in the front office, starting with the patient’s first call to schedule an appointment. Gathering detailed information and then confirming it at check-in contributes to proper patient identification. Having well-trained staff from the front desk all the way to the back-office staff is critical to ongoing success. Conduct regular staff meetings with training logs to reiterate practice policies and provide education. Doing so will foster teamwork and encourage clear communication between staff members.

When possible, it is also beneficial to build rapport with regular patients. There is value in having the patient treated by the same dental team members each time they visit the office to build trusting relationships and consistency of care. Include brief notes in the patient’s chart about their personal life, so that visits can start with a casual, friendly conversation that serves the dual purpose of confirming identity and demonstrating interest in the patient’s well-being.

In addition, the value of a timeout policy cannot be overstated. Pausing before beginning a procedure to review patient information and the treatment plan to eliminate potential errors or omissions is a critical preventive tool. Too often, the dentist trusts that all they need to do is walk in, say hello to the patient and get right to work. Instead, after greeting the patient, take time to verify that their information matches the chart or treatment plan on hand. Restate what you have down as the planned treatment or issue that the patient has come in for such as, “It looks like we will be beginning the process for a crown on the lower right for you today,” to verify that the patient’s expectations match the outlined treatment. Obtain informed consent and ensure all patient questions about the treatment are addressed.

Along with receiving verbal confirmation from the patient, an important aspect of any time-out policy is that the dentist also confirms patient information and treatment with another member of the dental team. During timeout, any team member can express concerns about the procedure verification, a vital safeguard to preventing treatment mistakes.

Increase the potential for a favorable outcome for you and the patient by taking the following steps:

• Inform your patients about treatment errors in a timely manner.
• Acknowledge that an error occurred and identify measures you have taken to prevent these in the future.
• Clearly communicate a plan to address the issue and provide a potential solution including any costs for which you will be responsible.
• Document in the patient chart what the patient was told about the error and your proposed corrective action.
• Do not bill the patient for a procedure performed in error. Doing so can provide motivation for the patient to file a malpractice claim.

CDA members who find themselves in situations involving the wrong tooth, wrong patient or any other treatment oversight can call TDIC’s Risk Management Advice Line for expert, no-cost assistance. Experienced analysts can guide you through options that will assist in a resolution and, in many cases, reduce the risk of litigation.

TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit tdicinsurance.com/RMconsult or call 1.877.269.8844.