It is possible for complications to arise during or after any treatment or procedure. In this case study, we examine risk management issues involving complications that resulted from an extraction procedure and outline strategies to help dental professionals enhance safety while mitigating risk.
A patient presented to her dentist for a scheduled tooth extraction and denture fitting. During the extraction, the patient complained of extreme pain and allegedly stated that it felt as if her jaw had been broken.
The patient was discharged home and returned the following day, presenting with a swollen and bruised jaw and complaining of pain.
A dental x-ray revealed a complete fracture of the left mandible. The dentist referred the patient to an oral surgeon, with a letter outlining the x-ray results and information stating his belief that the fracture may have occurred during the extraction of an ankylosed tooth. The dentist provided the patient with the original x-rays and dental record.
The oral surgeon diagnosed a left displaced mandibular fracture and admitted the patient to the hospital for surgical repair.The oral surgeon performed an open reduction internal fixation the next day, and the patient was discharged a day later.
Subsequently, the patient developed complications that required several additional surgical procedures. The patient alleged that the dentist was negligent in failing to properly document the extraction procedure, failed to maintain proper dental records, failed to take adequate x-rays prior to the procedure, caused the fracture by applying excessive force during the extraction, and failed to adequately assess the patient’s complaint by immediately obtaining an x-ray.
The plaintiff’s expert dentist opined that the dental care was below the standard of care and the direct cause of the injury and ensuing complications. Patient records from subsequent treating professionals revealed that the patient, who continued to have pain and loss of jaw function, became anorexic as a result of an inability to chew properly. The patient successfully pursued a professional liability claim against the dentist.
Risk Management Discussion
When an undesired result, injury, or serious complication occurs, it is often how the situation is handled that determines the outcome for both the patient and the healthcare provider.
In this case, when the patient complained of pain, the dentist did not stop to determine the source or severity of the pain and did not obtain a post-treatment x-ray. Although the dentist stated in a letter to the oral surgeon that he suspected the fracture had occurred during extraction of a specific tooth that was ankylosed, he did not document this information in the patient’s record, nor did he document discussions with the patient following the procedure. Because the dentist provided the patient with the original x-rays and dental record without keeping a copy, it was difficult to determine what information was documented by the dentist and staff.
The following strategies can help dental professionals improve quality and mitigate risk:
- Document the dental record with details regarding any complaint or complication that occurs during or following a procedure. Include your assessment and the actions taken to respond to the complaint or complication. For more information on documentation, see our article “The Faintest Ink: Documentation to Defend Quality Patient Care.”
- Retain all original records and x-rays. When a request is received for records and x-rays, make a complete copy and retain the originals in the office. When referring a patient to another care provider, supply copies of the dental record and x-ray films, but keep the originals. Document that copies were sent to the treating provider or given directly to the patient. See our article “Medical and Dental Record Issues: Frequently Asked Questions.”
- Maintain communication with the patient and other treatment providers. For known risks or complications, review your informed consent process to determine if the risk or complication was discussed. Continue to provide follow up conversations and care. In a study of plaintiffs who were asked why they chose litigation against their healthcare provider, most responded that they were seeking an apology and an explanation. It is important to provide both to a patient who is injured by a medical, dental, or system error. However, in many cases the cause of injury or complication is not known right away; therefore, it is equally important not to assume blame or to point to others as the cause of the complication or injury. For more advice on patient communication after a known risk or complication or an unforseeable event, see our “Disclosure Resources.”
- Consult with your malpractice insurance provider. When an adverse outcome resulting in potential or actual harm occurs, report it to your professional liability insurance company immediately for risk management advice. In this case, the dentist did not report the event until the patient retained an attorney.
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.