Inappropriate Dental Care and Delegation During Use of Conscious Sedation Lead to Patient Death

This case study examines factors that contributed to a tragic outcome for a dental patient placed under moderate (also known as “conscious”) sedation. The discussion includes strategies to help dental professionals keep patients safe during a treatment or procedure involving sedation or anesthesia.

A young adult underwent a procedure in an oral and maxillofacial surgeon’s office to extract four wisdom teeth. The surgeon placed the patient under moderate sedation and performed the procedure 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, followed by 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 arriving at the hospital. An autopsy revealed anoxic encephalopathy due to cardiac arrest. Factors that may have contributed to the patient’s cardiac arrest included the sedating agent and evidence of an undiagnosed viral infection.

A wrongful death suit was filed against the surgeon.

Risk Management Discussion

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 the cardiac arrest had not been determined, the licensing board sanctioned the surgeon. The board’s decision regarding the surgeon’s care included findings similar to those of the experts involved in the claim: failing to appropriately manage a medical emergency, allowing personnel to perform tasks beyond their legal scope of practice, and failing to provide appropriate surgical care and monitoring.

The following strategies can help dental professionals avoid patient injury when performing a treatment or surgical procedure with the administration of sedation or anesthesia:

  • Perform and document a presedation examination that includes the patient’s medical, surgical, medication, and anesthesia histories; any allergies; and an ASA physical status (using the American Society of Anesthesiologists’ Physical Status Classification System). Those patients with a status of >ASA II should be medically cleared prior to sedation.
  • Obtain a signed informed consent. Discuss the risks, benefits, and alternatives of the procedure and the use of sedation or anesthesia. Retain the signed informed consent form and document the discussion in the dental record.
  • Provide the patient with clearly written preprocedure instructions, including the need for NPO status. The instructions should be in simple language without technical terms and in the patient’s primary language.
  • Evaluate and document the patient’s medical condition (including current NPO status) immediately prior to initiating treatment. Examine the patient’s vital signs and airway and auscultate the heart and lungs.
  • Have an adequate number of assistive staff 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. Follow any state requirements on the training, certification, and use of assistants in procedures involving patient sedation.
  • Conduct a time out before each procedure. Include the patient and assistive staff.
  • Maintain Basic or Advanced Cardiac Life Support for all members of the care team who supervise, administer, or monitor conscious sedation. (This may be required by law in some states.) Document staff training and keep current certificates in employee files.
  • Ensure that emergency equipment, medications, and supplies are readily available, and develop written protocols for managing all types of emergencies. Make sure that staff members (including new or temporary staff or students) are properly trained in the protocols and on the location and use of equipment.
  • Review and follow all applicable state laws on emergency preparedness. Conduct periodic emergency drills and simulation training to aid in efficient and effective response to emergencies. Make sure that staff members can identify the signs of an urgent or emergent situation.
  • Assign tasks related to emergencies to individual staff members. Assignments include retrieving emergency supplies, checking patient vital signs, and calling 911. Establish a backup plan that addresses staff absences.
  • Verify the level of training and the roles of any students rotating through the practice, e.g., observation only or certain patient care tasks permitted. Do not delegate tasks to students or staff members that are outside their legal scope of practice and level of education and training.
  • Follow and document an equipment maintenance schedule according to the manufacturers’ recommendations to ensure that all monitoring and emergency equipment is working properly.
  • Inventory emergency medications on a regular basis and replace expired medications.
  • Follow all state laws, dental board requirements, and your malpractice insurer’s guidelines on reporting and disclosing adverse events.

For additional information, see our article “Moderate or Conscious Sedation in the Office Setting.” For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.


American Dental Association. Medical Emergencies in the Dental Office.

American Dental Association. ADA Policies on Anesthesia and Sedation.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology.
Anesthesiology 2018;128(3):437-479.

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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