Medical Error Prevention in Dentistry
In 1999, the Institute of Medicine (IOM) revealed that medical errors annually account for up to 98,000 hospital deaths and cost the U.S. economy approximately $17 to $29 billion. The shocking figures prompted a major co-initiative among federal bureaus, such as agencies within the Department of Health and Human Services, with the IOM to reduce medical errors and improve patient safety in federally funded health care programs, and by example and partnership, in the private sector. The Patient Safety and Quality Improvement Act was signed into law on July 29, 2005 with the purpose of establishing patient safety organizations which would collect, aggregate, and analyze confidential information reported by health care providers, identify failure patterns, and propose measures to eliminate patient safety risks and hazards. The Act is part of the IOMs vision for improving health care delivery and developing a first rate, patient responsive, 21st century health care system across the country.
Understanding Key Terms
Patient safety involves the prevention of healthcare errors, and the elimination or mitigation of patient injury caused by healthcare errors. The National Patient Safety Foundation further defines Healthcare Error as An unintended healthcare outcome caused by a defect in the delivery of care to a patient. Healthcare errors may be errors of:
- Commission doing the wrong thing
- Omission not doing the right thing
- Execution doing the right thing incorrectly.
Medical malpractice is a broad and obscure term that is often subjective to personal experience and opinion. However, there are certain parameters that have been set in order to recognize when it is present. These factors include:
- Failure to communicate the diagnosis
- Formulating an inaccurate diagnosis
- Lacking informed consent from the patient or the immediate legal family
- Surgical errors
- Mistakes in prescription of medication
When using sharp instruments on sensitive areas such as oral tissue, the difference between safe practices and a damaging accident may be only millimeters, turning a careless mistake, at a crucial moment, into an undesired medical error. Although harm does not result from medical error 100% of the time, reducing incidents of improper commission, omission and execution avoids preventable accidents and improves the healthcare outcome.
Medical errors are either active or latent. A latent error refers to an error in the planning, organization, training, or maintenance which leads to operator errors. The effects typically lie dormant in the system for lengthy periods of time. An active error pertains to an error in execution, occurring at the level of the frontline operator where effects are felt almost immediately. Latent errors occur due to poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations, which may then lead to active errors such as administering the wrong medication or incorrect charting notes.
Adverse events related to surgery accounted for two thirds of all adverse events and 1 of 8 deaths in a study at Colorado and Utah hospitals in 1995 as reported in JAMA, the Journal of the American Medical Association.
Dr. Stanley Malamed, author of Medical Emergencies in the Dental Office, indicates a medical consultation is indicated before any treatment that involves a degree of hemorrhage (e.g., periodontal surgery, oral surgery) if the patient is currently receiving anticoagulant or anti-platelet therapy. The doctor should take precautions to prevent postoperative hemorrhage from occurring. Possible steps include a haemonstatic dressing placed within the socket, multiple sutures in the surgical area, intraoral pressure packs, extra oral icepacks, the avoidance of mouth rinses, and a soft diet for 48 hours following the procedure.
Dr. Malamed also advises dentists to verify that adequate analgesic has been administered prior to the surgery to ensure the patient feels no pain, and for the dentist to aid in the postoperative control of pain and anxiety in the patient. After a surgery, the dentist should:
- Be available by telephone 24 hours a day
- Monitor pain control and prescribe analgesic medication as needed
- Prescribe antibiotics if a possibility of infection exists
- Prescribe anti-anxiety agents, if in the doctor’s opinion they may be required by the patient
- Prescribe muscle-relaxant agents after prolonged therapy or following multiple injections into one area (such as inferior alveolar nerve block).
Providing a patient with the adequate medical and moral support after surgery should be a standard practice in dentistry, because the medical procedure ends when the patient feels better, not as soon as he or she is out of the surgical room or dental office.
Healthcare practitioners see many patients monthly who suffer from different ailments. This can be stressful and confusing. Carefully noted medical charts and records remind dental professionals of each patient’s specific condition.
Before administering a drug, a dentist must always ask whether the patient is allergic and consult the patients chart to see if he or she is taking any medication or has a condition that may cause an adverse reaction. Dental professionals must also be careful when writing the prescription, verify the right drug and dosage, and advise the patient to take it correctly.
With regards to anesthesia, Dr. Malamed comments, Dosage is a highly significant factor. Within the clinical dosage range for most local anesthetics, there is a linear relationship between dose and maximal blood concentration. The larger the dose of local anesthetic injected, the higher the ultimate blood level of the drug will be.
Dr. Malamed also points out that it has been reported with increasing frequency that certain individuals possess genetic deficiencies that alter their responses to certain drugs. He provides the example of the genetic deficiency in the enzyme serum cholinesterase. Produced in the liver, this enzyme circulates the blood and is responsible for the biotransformation of two important drugs: succinylcholine and the ester type of local anesthetics. Thus due to individual patient physiology, a dentist should take precautions not to administer a drug that may have adverse results.
A correct diagnosis is the primary requisite for accurate and effective procedures, treatment, and prescriptions. A misdiagnosis may endanger a patient by delaying treatment or prescribing an ineffective medicine or unnecessary procedure. Inexperience with a technically difficult diagnostic procedure can affect the accuracy of the results and be costly or invasive.
The Council of State Governments issues a pamphlet titled State Regulatory Policies: Dentistry and the Health Professions. Dentistry means the healing art which is concerned with the examination, diagnosis, treatment planning and care of conditions within the human oral cavity and its adjacent tissues and structures. Dental practitioners are expected to have a thorough understanding of these fundamentals and be alert to early warning signs of possible disease.
Systemic factors contribute significantly to preventable adverse events, and in fact, medical errors may result most frequently from faults in the organization of health care delivery and the way resources are provided to the delivery system. Efforts to reduce medical errors in an organization require changes to the system design, including possible reorganization of resources by top level management.
With the continual development of technology, the practice of medicine both improves and deteriorates. More complex treatments and dental procedures often allow more room for errors. Often understaffed and not adequately trained, dental offices and other dental care facilities experience serious technical difficulties. Advanced technology has made dental equipment efficient and reliable, but all are human operated and thus imperfect. Training dental staff to understand and operate dental equipment is crucial, but so is maintaining the equipment and checking it on a regular basis to maintain its safety.
All professionals are prone to make mistakes. Although most cases of dental malpractice involving human errors are not intentional, they must still be reported and properly addressed. The IOM reports the following factors may endanger patient safety:
- Fatigue: due to working long hours
- Use of alcohol or other drugs by medical staff, often caused by the high stress of the profession and easy access to medications
- Illness: coming to work when not well jeopardizes the medical employees health as well as the health of the patient under his or her care
- Inattention/Distraction: a noisy, busy dental office makes it difficult to concentrate on one patients care, especially when others are waiting
- Emotional states: anger, anxiety, boredom or fear can all impair job performance
- Communication problems: lack of clear and friendly communication among the staff or between health providers and patients
- Equipment design flaws: training and experience with equipment are key to avoiding errors
- Hard-to-read handwriting: dentists must write legibly on prescriptions and reports
- Unsafe working conditions: poor lighting or slippery floors, as well as a disorganized working environment, can lead to chaos.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) notes two common factors contributing to medical errors include: 1) multiple procedures performed during a single visit and 2) unusual time pressure which speeds up procedures.
The National Patient Safety Partnership, spearheaded by the Veterans Administration, released a list of 16 best practices for medication safety in 1999. Some valuable tips for healthcare professionals to help ensure patient safety include:
- Educate patients
- Put allergies and medications on patient records
- Stress dose adjustment in children and older persons
- Limit access to high hazard drugs
- Avoid abbreviations
- Standardize drug packaging, labeling and storage.
A Properly Trained Staff in Case of Emergency
Without any doubt the most important step in the preparation of a dental office for medical emergencies will be the training of all office personnel, including non-chair side personnel such as receptionists and laboratory employees, says Dr. Malamed. All dental personnel need adequate training in administering cardio-pulmonary resuscitation (CPR), and advanced cardiac life support (ACLS). Although medical emergencies are rarely seen in dental offices, every care facility must be ready in the case one occurs; a trained staff can save a patients life.
The dental team should also have a plan in case of an emergency, designating different employees to carry out certain tasks. For example, one employee should provide basic life support and stay with the victim, while another retrieves the emergency kit, and a third monitors vital signs and keeps records of the incident.
Videotapes are a useful learning tool which provides dental staff with visual examples of what can take place during an emergency situation. They can exhibit the best procedures to implement. Emergency telephone numbers should be clearly displayed by all dental office phones. These should include immediate contact information for ambulance service, nearby hospital emergency room, or local emergency medical services (EMS).
Emergency Phone Numbers and Drug Kit
Aside from emergency phone numbers, emergency drug kits are also valuable. Although there are many commercial brands of drug kits, Dr. Malamed suggests the most desirable approach is for the doctor to prepare a kit that is individualized to meet his or her special requirements and capabilities. This is true in the sense that the dental emergency kit need not, and should not, be complicated since complexity in adversity breeds chaos.
According to Dr. Malamed, there are three points that dental professionals should keep in mind when it comes to emergency medication:
- Drugs are not necessary for the immediate management of most emergencies
- Primary management of all emergency situations is basic life support (BLS)
- When in doubt, never medicate.
Patient Safety Tool Kit
The American Dental Association (ADA) reported in 2008 the Agency for Healthcare Research and Quality (AHRQ) has created 17 ways to help health care providers and patients improve communications, enhance patient safety, and reduce medical errors. These toolkits, available online and free of charge, include a variety of evidence based training materials, medication guides and checklists which help to reconcile the discharge of a patient from one facility to another. They are adaptable to many health care settings from emergency departments to intensive care units to outpatient facilities and have been equally intended for dentists, physicians nurses, hospital managers, and others providing safe, quality health care at any point in the health care process. For a complete list of topic areas or to access toolkits online, log on to the Agency for Healthcare Research and Quality (AHRQ) at www.ahrq.gov/qual/pips.
Error Prevention and Reduction
Preventing Medication Errors
Most of the time the medications people take are beneficial, or at least they cause no harm, but on occasion they do injure those taking them. Some of these Adverse Drug Events, or ADEs , are inevitable: the more powerful a drug is, the more likely it is to have harmful side effects, but sometimes the harm is caused by an error in prescribing or taking the medication, and these damages are not inevitable. To aid in decreasing medication errors, the IOM recommends:
- Enhance doctor/patient communication
- Suggest steps patients should take to protect themselves
- Improve packaging, naming and labeling of drugs to reduce confusion
- Key in prescriptions electronically
- Create easy to understand drug information resources for the patient.
Improving Patient Safety
Studies funded by the AHRQ, an agency of the U.S. Department of Health and Human Services, have indicated three computerized methods which reduce reliance on human memory and have shown promise in helping to reduce errors while raising efficiency: computerized ADE monitoring, computer-generated reminders for follow-up testing, and standardized protocols.
- Computerized ADE Monitoring Although determined less accurate than chart review and voluntary identifying of adverse drug events, it saves five times the personnel time in tracking drug errors
- Computer-Generated Reminders for Follow-up Testing Have reduced the number of patients subject to unnecessary repeat testing, and reduced the time until appropriate treatment could be administered
- Standardized Protocols Have increased survival rates of patients in intensive care and may raise the efficiency of decision support systems.
Prevention attempts to eliminate an error before it happens. Risky situations exist in the dentistry field, such as infections and the spread of HIV and other viruses, but proven steps can prevent and control them. The human oral cavity is home to over 500 different strains of bacteria at any given time and infections are one of the main concerns of dental professionals.
Research shows that protection against infection and cross-contamination is an important preventive measure. Over 65 percent of the adult U.S. population is treated at a dental facility each year. Thus, the dental staff has a professional and ethical duty to protect patients from blood and fluid borne pathogens.
Some preventive methods to control infection and cross-contamination are:
- Hand-washing as a standard and common practice between dental employees
- Use of personal barriers such as gloves, eye shields, facemasks and disposable gowns by dental staff
- Properly dispose of these items after use following hazardous waste guidelines
- Clean office equipment that may be contaminated during a procedure, such as: lamp handles, bracket handles on tables and trays, hoses and handles, switches and chair controls, and patient X-rays and charts.
Many microbial pathogens, from HIV to tuberculosis, can possibly survive from 2 hours to 8 months on the surface of contaminated equipment. Thus, disinfecting these surfaces should be accomplished between patients using an approved medical disinfectant. Another important guideline to avoid the spread of deadly diseases such as the HIV virus is the correct handling of sharp objects. Some reminders are:
- Needles should never be recapped
- All “sharps” must be disposed of in approved, one-way depository containers and should be clearly marked as BIOHAZARDOUS WASTE
- “Sharps” containers should be disposed of properly when 3/4 full.
Another important factor to remember is that certain physical conditions in the patient may complicate certain medical procedures. For example, the introduction of any prosthetic device, whether joint implant, pacemaker, or heart valve, increases patient risk for focal infection; implants provide a healthy medium for bacterial colonization and infection.
In the case of a patient with joint replacements, the ADA recommends a course of prophylactic antibiotic treatment to prevent risks of bacterial build up. In these particular cases, the dentist should consider treatment on an individual basis and consult with the patients physician or orthopedic surgeon to evaluate the risks of joint infection in that patient.
A bite to the inside of the cheek, lip or tongue can provide an easy route for transmission of oral bacteria into the bloodstream of the soft tissues. Thus, dentists are responsible for treating these lesions first and forming a diagnosis of whether these lesions signal a more serious disease such as HIV or oral cancer.
Also keep in mind that prior to performing routine, elective, or invasive dental procedures, oral care practitioners may prescribe a regimen of antibiotic medication as dictated by the patient condition. Amoxycillin, ampicilin, erythromycin, and penicillin are among the prescribed medications that have proven effective on oral bacteria.
Root Cause Analysis
Evidence based risk assessment instruments can prevent future errors from happening by determining the cause of the problem. This is the concept behind Root Cause Analysis, or RCA. The JCAHO defines the process as identifying the basic or causal factor or factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. The objectives of a Root Cause Analysis are:
- First, find out first what happened
- Second, why did it happen
- Third, what factors contributed to the event
- Finally, what can be done to prevent it from recurring.
Two essential factors leading to the success of an RCA are: 1) striving to maintain the highest degree of impartiality possible, and 2) not approaching the case with pre-existing judgment.
According to the National Center for Patient Safety, a thorough RCA must include:
- Determination of human and non-human factors.
- Determination of related processes and systems.
- Analysis of underlying cause and effect systems through a series of WHY questions.
- Identification of risks and their potential contributions.
- Determination of potential improvement in processes or systems.
The results of RCAs commonly point to: system failures, risk management flaws, and substance abuse by healthcare professionals; as the cause of the error.
Stress on both the patient and the dental staff can cause procedural errors with unfavorable consequences. Emergency situations in dental offices may develop quickly with a failure to follow protocol. Flaws within a dental practice, such as poor communication between staff, health care providers and patients have contributed to the recurrence of errors. Dentists routinely manage these and other risks in daily practice. Risk management strategies encompass the application of risk assessment and communication, plus workplace issues of anti-discrimination, record keeping, privacy, security, fraud, and abuse.
For the ten year period between 1997 and 2007, the Physicians Insurer Association of America (PIAA) reported the average indemnity payment for claims against dental practices and practitioners doubled, from $63,000 to $138,000 per claimant. This is faster than the rise in payments to primary and specialty care providers, although the figures are half that of the indemnity claims against physicians. In fact, most claims closed with much smaller payouts to the patient.
Common malpractice claims dental practices encounter include:
- Failure to diagnose, such as periodontal disease or oral cancer
- Carrying out an inappropriate or unnecessary procedure
- Neglecting informed consent
- Failure to refer for additional care
- Operations on the wrong tooth.
When seeking liability coverage for a practicing professional or dental practice, an oral healthcare provider should consider the reputation and solvency of the insurance carrier. A reputable carrier should be authorized to do business in multiple states; if the practitioner relocates, it is easy to adjust the policy, rather than attempt a new coverage application. The carrier should show a measure of financial stability. This can be determined by checking with industry rating agencies such as AM Best and Standard & Poors. The practitioner should also be concerned with the carriers litigation philosophy and history. Companies that vigorously defend against malpractice suits are more desirable to retain than those that quickly close cases in favor of the plaintiff.
Practitioners must also weigh the affordability of policies with the cost and likelihood of particular malpractice claims. Large dental practices may subsidize practitioners liability insurance costs. States which have enacted tort reform laws have put caps on the damage amounts in liability claims and are friendly to the healthcare provider. Tort reform has limited claims for non-economic damage in some states, that is, amounts awarded for incidences of pain & suffering, lost wages, and future dental care. Without tort reform, a practitioner might consider carrying higher insurance limits; although such liability amounts should be comparable to others in the workplace, no one should become a lightning rod in a malpractice suit!
All members of a dental practice should be experienced in patient communications, thus mitigating malpractice risk with house policies that insure patients understand both the risks of care and their financial obligations before giving informed consent. Especially in the case of cosmetic dental procedures, the dentist and staff should accurately assess a patients expectations for positive outcomes. Documenting not only treatment procedures and results, but also patient interactions, such as conversation and even body language, can be beneficial should an incident of malpractice arise. Establishing more efficient teamwork between dental employees and more personal respectful relationships between dentists and patients can only lead to better oral health outcomes and business practice results.
Charitable Immunity Protection
Oral care providers who volunteer their services may have some liability protection under state and federal laws. Many states have enacted charitable immunity laws that offer some legal protection to health care volunteers. The Federal Volunteer Protection Act protects certain volunteer clinicians from claims of simple negligence. The ethical responsibilities of participating dentists must also be considered when analyzing the applicability of immunity laws. Risk management planning should involve an assessment of applicable laws and the impact on potential liability of the society and volunteers.
As in the case of medical malpractice, there are specific factors which determine a case of dental malpractice. These four factors are: breach of duty, duty of care, proximate cause, and injury:
- Breach of duty – the dentist did not provide competent dental care
- Duty of care – the dentist had an obligation to provide competent dental care
- Proximate cause – the patient’s injury was a result of the dentist’s breach of duty
- Injury – the patient was injured while undergoing dental procedures.
There is a kind of law meant to protect patients that have been victims of malpractice. It is called personal injury law and according to the legal website, The Dentalaw Group at www.dentalaw.com, it is an area of law that seeks to recover damages (compensation) for victims of physical or mental injury that has occurred due to the action (or inaction) of another.
Personal injury law protects patients which have been victims of malpractice. From the Dentalaw Group, a dental malpractice resource center at www.dentalaw.com, [this] area of law seeks to recover damages (compensation) for victims of physical or mental injury that has occurred due to the action (or inaction) of another. and personal injury cases can be filed by the victim, or loved ones, on three bases: negligence, strict liability, and intentional wrong. These are situations which all dental professionals should be aware of and avoid:
- Negligence – this type of personal injury case includes those injuries that allegedly occur due to the inaction of another (failing to follow safety regulations, etc.)
- Strict Liability – this type includes injuries that allegedly occur due to a defective product
- Intentional Wrong – this type of case includes injuries allegedly inflicted upon the victim intentionally.
Examples of Dental Malpractice
In addition to the aforementioned common malpractice claims dentists experience, there are four more examples:
- Failure to advise patient of diagnosis
- Improper diagnosis
- Lack of informed consent
- Dental procedure error resulting in injury to the patient
- Medication errors.
According to the Dentalaw Group, “there are several cases of dental damage that can take place while a patient is undergoing a medical treatment.” These may include:
- Nerve injury to the jaw, lips, and tongue
- Anesthesia injury – this also includes anesthesia deaths
- Injury to the bones of the jaw
- Injury to the teeth or gums from a faulty crown or bridge
- TMJ Dysfunction Syndrome resulting from orthodontic treatment
- Injuries or infection resulting from use of dental products.
Actual Dental Malpractice Cases
Though many times not publicized, accidents happen in the dental profession, and are many times overlooked. There have been some notorious instances of both negligence and malpractice in the dentistry field.
Such is the case of a 40-year-old part-time Florida nursing student and housewife with negligence in crown and bridge treatment prior to periodontal treatment resulting in periodontal surgery and new crowns. This case was settled prior to trial for $47,500 and was disclosed to the Dentalaw Group:
The plaintiff, a 40 year old part-time nursing student and housewife was examined by the defendant’s associate who told her that she needed many of her teeth capped but that she first had to have periodontal treatment. At the next visit, the plaintiff was seen by the defendant who started to prepare her teeth to be capped and told her that her periodontal condition wasn’t so bad. During treatment the patient requested that the defendant cap all of her teeth for aesthetic considerations and he complied. A few months after all of the crowns and bridges were cemented the patient visited a new dentist for routine cleaning and was told to run, not walk, to the nearest periodontist. Upon examination by the periodontist, the patient learned that she needed four quadrants of periodontal surgery which she promptly had performed. Following the surgery, the gingival margin occupied a healthier position which was now 1-3 millimeters away from the metal margin of the crowns which was then visible and unsightly. Thus, the plaintiff had to have all the crowns cut off and replaced. Specials (new crowns and periodontal surgery) were $9,000.
Another actual account found on this legal site is that of a 30-year-old Florida man who needed a root canal due to a temporary bridge coming loose. The case settled for $7,000.00 at a mediation conference::
Plaintiff was a 30 year old pressure cleaning mechanic who underwent the construction of a three unit dental bridge by the defendants general dentist. The temporary bridge came loose shortly before the permanent bridge was to be cemented and the plaintiff walked around without the temporary for a few days. During that interval, the teeth shifted and when the plaintiff returned to the defendant for the final cementation of the bridge, the bridge wouldn’t fit.
The defendant attempted to machine out the inside of the molar crown of the bridge and ground down the molar, which significantly traumatized the nerve. The bridge was eventually cemented but the patient was in extreme pain. The subsequent treating dentist had to do a root canal on the molar which relieved the patients pain.
Once he was out of pain, the patient quit the subsequent treater, complaining that his fees were too high. He began seeing another subsequent treater but never returned to have the bridge finished, by either of his two subsequent treating dentists.
Legal and Financial Consequences
Aside from the physical and emotional suffering an erroneous diagnosis can cause a patient, the dentist is also adversely affected. Even if a case is settled and the dentist does not lose their practicing license, settlement fees can be high and medical reputations ruined, thus diminishing clientele base and possibly ending a successful dental career.
The high settlements against healthcare professionals for medical malpractice suits make it a necessity to pay increasingly higher premiums for malpractice insurance. Many view it as a vicious cycle: the higher the insurance premium the dentist has to pay yearly, the more he or she is pressured to work and make profit, and the more room there is for error in the dental office.
Healthcare Professionals on Trial
Once an event happens, you cannot rewind the tape, erase it or do it over. A fraction of a second can be the difference between a successful medical procedure and a suffering patient. When malpractice has already taken place and there is nothing to be done to prevent it, often what follows is a complex legal and emotional trial.
Malpractice trials are economically and emotionally draining for both the patient plaintiff and the dental professional defendant. Know your rights and responsibilities. The risk management department of your dental liability insurance carrier is equipped to answer questions related to liability issues and malpractice events. Use them as your first resource.
McClellan (p.4) states, the author of Medical Malpractice: Law, Tactics and Ethics, that during a trial:
The defendant physician is subjected to piercing cross-examination in an environment that is unfamiliar and potentially hostile. In this environment, the doctor’s ego, competence, and knowledge are challenged and scrutinized in a manner to which he is unaccustomed. Physicians live and work in a social structure that encourages them to act as if they are in control and indeed demands that they do so. The legal system, on the other hand, turns the defendant into a passive participant who must rely on others to play the dominant roles in resolving the dispute.
Trials are economically and emotionally draining for both the patient (plaintiff) and the dental professional accused of malpractice (defendant). However, the legal process is inevitably linked with the dental profession, especially when it comes to malpractice and knowing some of the legal terms and procedures involved in these cases is an essential part of any dental professional’s training.
Although remarkable advances have been made in the field of dentistry, it remains a practice of both art and science and greatly depends on the skills of its practitioners. Practicing dentistry requires an innate love for human kind and the act of healing others.
Dental professionals are expected to have an ethical and professional understanding of their responsibilities to their patients. Since human suffering can result from errors, both for the patient and the dental professional, oral health practitioners must continually improve techniques to insure patient safety and to minimize medical errors. In turn, this will assure a sound risk management program and protect practitioners against malpractice suits, the worst consequences resulting from medical error.