Case Study: Process Failures Lead to Patient Harm

Susan L. Marr, MSA, CPHRM, Senior Patient Safety Risk Manager, Department of Patient Safety and Risk Management

When choosing an alternative treatment plan that deviates from the prevailing standard of care, a dentist should always thoroughly document the clinical justification in the dental record.

The patient, a 46-year-old male, contacted his dentist after experiencing severe tooth pain. The dentist’s notes described a “small area of what appears to be infection around tooth #18”. No x-rays were obtained. For unknown reasons not documented in the records, the dentist elected to extract teeth #19 and #18 in the area of the pain. He did not have the patient sign a consent form, and he did not prescribe an analgesic or antibiotic. The patient was not given a follow-up appointment and did not receive follow-up instructions from the dentist.

The patient’s pain continued to worsen. Having lost confidence in the original treating dentist, he elected to see another dentist. X-rays by the subsequent treating dentist revealed that the infection had spread significantly, and teeth #17 and #20 were now involved. The dentist recommended extracting teeth #17 and #20 and removing a small portion of the gum. With the patient’s informed consent, he performed the procedures and provided antibiotic therapy and pain control. In the opinion of the second dentist, the successful treatment was initiated “just in time, before the consequences could have been much more serious”.

The patient pursued a claim against his original dentist. Expert reviewers noted that appropriate care by the original dentist would have included obtaining dental radiographs and placing the patient on antibiotics and pain medication as needed.

Risk Management Discussion

Failure to diagnose is a common issue in dental claims. In this case, the original dentist failed to treat the obvious infection and further complicated matters by undertaking a procedure that subsequent experts found to be contraindicated. Reviewers were also critical of the original dentist’s documentation, noting that justification for deviating from the standard of care should be thoroughly documented.

The following strategies can help dentists avoid issues in the case study:

  • Adhere to the prevailing standard of care. If an alternative plan of care is chosen, document clinical justification for making that choice.
  • Obtain informed consent from the patient. Provide descriptions of the procedure, alternative treatments, risks and benefits, expected outcome, and the rationale for the proposed treatment using terminology the patient can understand.
  • Confirm the patient understands by asking him or her to summarize the details of your discussion. Solicit the patient’s expectations of the outcome.
  • Address any misunderstandings and unrealistic expectations. Document the discussion in the dental record and note the patient voiced understanding.
  • Schedule a follow-up appointment at an appropriate time interval to assure the patient is healing appropriately.
  • Instruct the patient to call the office if the symptoms do not improve or worsen.
  • Consider having a member of your office staff make a follow-up phone call the day after the procedure to check on the patient’s condition.

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

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.

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