Case Study: Inappropriate Delivery of Care and Delegation Lead to Patient Death

Sandra Strickland, MSN, CPHRM, Assistant Vice President, Department of Patient Safety and Risk Management

Adequate preparation for medical emergencies may prevent harm.

A 20-year-old female underwent a procedure to extract four wisdom teeth. Her oral and maxillofacial surgeon placed her under conscious sedation, and the procedure was performed in his office. The surgeon was assisted by a licensed dental assistant and a student intern.

During the process of removing the fourth tooth, the dental assistant noted that the patient’s blood pressure increased rapidly. The patient’s pulse rate dropped, and she subsequently went into cardiac arrest. The student intern was unable to locate emergency equipment, which caused a delay in initial attempts to resuscitate the patient. Paramedics were called and the patient was rushed to a nearby hospital emergency department. Despite resuscitation, the patient began having uncontrollable seizures and expired less than 12 hours after arrival to the hospital. An autopsy revealed anoxic encephalopathy due to cardiac arrest. There were several factors that may have contributed to the cardiac arrest, including the sedating agent, as well as evidence of an undiagnosed viral infection.

A wrongful death suit was filed against the surgeon. Experts faulted the surgeon on several issues: failure to evaluate the patient’s medical condition prior to initiating the procedure, improper delegation to untrained staff members, failure to monitor the patient adequately, failure to respond to a medical emergency, and failure to provide appropriate surgical care.

The dental licensing board also investigated the case. Although the surgeon was highly qualified and the cause of cardiac arrest had not been determined, the licensing board sanctioned the surgeon. The faults of the surgeon stated in the board’s decision were similar to those of the experts involved in the claim: failure to appropriately manage a medical emergency, allowing personnel to perform tasks beyond the legal scope of practice, and failure to provide appropriate surgical care and monitoring.

Risk Management Discussion

Failure to evaluate the patient’s medical condition prior to initiating a procedure and improper delegation to untrained staff members were significant patient safety issues in this case. In addition, the failure to adequately monitor the patient and the lack of defined procedures to respond to a medical emergency were considered contributing factors in the death of this patient.

The following guidelines can help you avoid patient injury when contemplating performance of a treatment or surgical procedure with or without the administration of sedation or anesthesia:

  • Evaluate and document the patient’s medical condition prior to initiating treatment. Assess the patient’s medical, surgical, medication, and anesthesia histories and note any allergies.
  • Obtain a signed informed consent. Discuss the benefits as well as the risks of the procedure and the use of sedation or anesthesia. Retain the signed informed consent form and document the informed consent discussion in the dental record.
  • Ensure the adequate number of assistive staff is involved in the patient’s care. Generally, a minimum of two trained staff members is required—one to assist the dentist or surgeon, and one to monitor and support the patient.
  • Ensure staff members have received appropriate and required training, including monitoring a sedated or anesthetized patient and emergency response, including Basic or Advanced Cardiac Life Support.
  • Ensure emergency equipment, medications, and supplies are readily available and staff members are properly trained in the location and use of equipment. Periodically inventory emergency medications and replace expired medications.
  • Conduct periodic emergency drills to aid in efficient and effective response to emergencies. Ensure monitoring equipment is available and working properly.

Contact the Department of Patient Safety and Risk Management for guidance and assistance in addressing any patient safety or risk management concerns.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J10569 06/16