Improving Patient Safety with a Timeout Policy

Patient safety remains a top priority for practice owners and dental teams; however, the dental office can often be a fast-paced working environment with various distractions that can impede best safety practices. Dental teams should be reminded that taking shortcuts often come at a high cost. Taking the time to check procedure details protects the patients and practice and minimizes the risk for liabilities.

In an effort to better prevent mishaps, the Joint Commission requires accredited dental practices to implement a timeout before all surgical procedures.

A timeout is the last in a series of steps established by the Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery and is defined as an immediate pause by the entire surgical team to confirm the correct patient, procedure and site.

Even if it’s not required for some dental offices, all practices should strongly consider implementing a timeout policy to help avoid the wrong teeth from being treated or extracted. A case reported to The Dentists Insurance Company’s Risk Management Advice Line illustrates the need for consistent timeouts to confirm procedure details. The dentist had referred a patient to an endodontist for an evaluation on teeth Nos. 14 and 15. After taking the necessary diagnostic radiographs and conducting further testing, the endodontist identified tooth No. 14 as the source of her complaint and recommended root canal therapy. The patient returned the following day for the treatment.

Halfway through the procedure, the endodontist realized that he had accessed the wrong tooth and was working on tooth No. 15 instead of tooth No. 14. He immediately completed a root canal on tooth No. 15 to repair his mistake and then began the root canal on the correct tooth.

After completing the procedure, the endodontist informed the patient of the incident and offered to waive the fee for treatment on both teeth. He also promised to take care of tooth No. 15 should it require treatment in the future.

A few days later, the office received a demand letter from the patient regarding the “mistake of drilling” the wrong tooth, asking the endodontist to make restitution for his error.

The endodontist was dealing with health complications at the time and did not want to risk the patient involving an attorney and adding more to his stress levels, so he contacted TDIC for assistance with resolving the issue. After multiple discussions, the TDIC claims representative and the insured were able to reach a settlement with the patient in exchange for signing a release of liability form.

Conducting a Timeout with the Dental Team

Prior to invasive or irreversible treatment, a timeout is a vital step in ensuring the correct patient receives the intended treatment at the proper site. All team members, including the dentists, dental assistants and front desk staff play a significant role in conducting a timeout.

The timeout is initiated by a designated member of the treatment team, usually the dentist, and begins with a preprocedure verification of the patient, the procedure and the site of the procedure to be performed. It also involves interactive verbal communication with the patient, if possible, and all team members. Any team member is able to express concerns about the procedure verification.

The timeout is conducted in a fail-safe mode, meaning that the procedure is not initiated until all questions or concerns have been resolved. It also includes a process for reconciling differences in responses among team members. The completed components of the timeout should be clearly documented in the patient’s records.

The Joint Commission does not require providers to individually document each step of the timeout. One checkbox or a brief note regarding the successful completion of the timeout, located in a consistent location in the patient record, is adequate documentation as long as the full content of the timeout is specified elsewhere, such as a policy handbook, according to the Joint Commission.

The Joint Commission’s Universal Protocol also includes surgical site marking; however, surgical site marking is not a feasible method for dental procedures. Therefore, dental professionals are considered exempt from the site-marking requirement.

The Joint Commission recommends dentists and oral specialists completed the following steps:

• Review the dental record including the medical history, laboratory findings, appropriate charts and dental radiographs. Indicate the tooth numbers or mark the tooth site or surgical site on the odontogram or radiograph to be included as part of the patient record.

• Ensure that radiographs are properly oriented and visually confirm that the correct teeth or tissues have been charted.

• Verify completion of the informed consent process, ensuring any questions or concerns from the patient are addressed.

• Conduct a timeout to verify patient, tooth and procedure with an assistant present at the time of the extraction.

• For patients referred to a specialist, review the referral slip to verify the tooth for which the patient was referred

Employers Could Be Held Liable for Employee Negligence

In addition to conducting a timeout before treatment, practice owners and dental teams should undergo the verification process anytime the responsibility of care for the patient is transferred to another dentist within the practice or when the patient is being referred to another provider for treatment.

In many cases, the practice owner could be held vicariously liable for the negligence of their employees.

In another case reported to the TDIC Risk Management Advice Line, a patient arrived at the dental office for a tooth extraction that had previously been diagnosed by the practice owner. The extraction was performed by an associate dentist who was not involved in the initial consultation with the practice owner.

The patient returned to the dental office a few days later for fillings on a different quadrant with a different associate dentist. After reviewing the patient’s treatment plan, the dentist noticed that the subsequent associate had extracted the wrong tooth.

The dentist informed the patient and recommended a consultation with the practice owner. After learning about the issue, the practice owner reassured the patient that he would do whatever it took to fix the problem.

A short time later, the dental office received an intent to commence litigation notice from the patient’s attorney.

In this case, the treating dentist was not insured with TDIC and the outcome of the case is not available; however, this case underscores how easily a wrong site procedure can occur without the implementation of a timeout and how quickly these incidents can escalate. Had the associate dentist verified the details of the procedure prior to beginning treatment, this incident could have been easily avoided.

Even though the practice owner is not the one who performed the procedure, they could be held liable. Employers are considered responsible for their employees’ actions while they are on the job and are considered to be able to prevent and/or limit any negligence by the employees. It is in the practice owner’s best interest to exercise reasonable care to prevent negligent behavior.

A timeout policy promotes a patient-centered safety environment of team members who are all empowered to work on behalf of the patient.

By implementing a timeout policy in the dental office, the practice owner is opening the lines of communication between all members of the team and creating a safe space for team members to feel comfortable enough to speak up before, during or after a procedure.

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 800.733.0633. For Risk Management guidance in Idaho, Oregon or Washington, call 800.452.0504.