May 2024 | 27 then exercised his malpractice policy provision which permitted him to refuse a settlement on his behalf. Sarah and her attorney accepted the settlement offer on behalf of Dr. O and prepared to go to trial against Dr. G alone. But as that date approached, Dr. G ultimately decided that the stress and lost time from practice were not in anyone’s best interests, so he agreed to allow his carrier to make a settlement payment on his behalf, thereby ending the case. Takeaways Here, as in many dental malpractice circumstances, there are multiple factors which led to the improper treatment of this patient; had any one of those elements been realized and eliminated from the chain, Sarah would have had her wisdom tooth removed and her central incisor restored. It is far from uncommon for nondental office staff members to play critical roles in untoward outcomes, whether by misinterpreting what is said to them and passing on that incorrect information to patients or other providers, or giving dental or medical advice to patients without a dentist’s knowledge or input, or making scheduling changes which delay time-sensitive treatment. Non-dental staff are not aware of nuances relating to patient care to a degree adequate to allow for significant decision making, but their actions are legally attributed to their dentist employers, so dentists are wise to realize this and, therefore, closely monitor the actions of staff. In this situation, neither Dr. G’s office manager nor Dr. O’s receptionist likely understood the multiple—and sometimes confusing— ways that teeth are numbered, directly leading to the first mistake. Both Drs. G and O bear legal liability for the actions of their employees. When Dr. O saw the handwritten schedule entry of “extract the upper right #8,” he could have broken the error chain by considering what he clearly knew: that there are at least three tooth numbering systems in use—the universal system (#1–32), the Palmer system (quadrants of upper right, upper left, etc. with teeth numbered in each quadrant from 1–8 moving back from the midline), and the FDI system (referring to the quadrants in clockwise fashion from 1–4 and numbering the teeth from 1–8 in each numbered quadrant as in Palmer). So, the upper right third molar can be referred to as #1, UR8, or 18 (not to be confused with the lower left second molar, #18), respectively, and the upper right central incisor can be called #8, UR1, or 11 (not to be confused with the upper left canine, #11), respectively. There is no getting around the fact that these classifications are easily and often mixed up, complicated by the vintage and geography of the individual dentists involved. So, before performing any invasive dental procedure, especially when a referral is involved, it behooves the referring dentist and the referred-to dentist to be 100% certain of the tooth to be worked on. Had Dr. G taken the time to send a written communication of the desired treatment to Dr. O, or had Dr. O taken the time to call Dr. G before starting treatment, or had some combination of those actions taken place, the mistake would have been averted. Furthermore, had Dr. O not limited the informed consent process to simply giving the patient a form to sign in the waiting room, and delegated the potential back-and-forth discussion to front desk personnel, but instead fully discussed the treatment with Sarah before the sedation began, the mistake would have been averted. Dentists have lagged well behind their medical colleagues in the consistent taking of a “time out” prior to the start of invasive procedures. That process, which takes only a short time, involves the input of the entire procedure team to assure the correct patient, the correct procedure, the correct site, the correct side, and any other specific precautions determined by the person in charge to be prudent. The importance of a “time out” cannot be overstated in its effectiveness in preventing wrong-site surgery: a retrospective study of non-emergent surgeries at Vanderbilt Medical Center in 2016, and published in the journal Anesthesia & Analgesia in 2020, found that there had been no wrong-site or wrong-person surgeries when a “time out”—averaging less than one minute in duration—had been taken prior to incision; a JAMA Network publication from 2018 reported 95 wrong-patient, wrong-site, or wrong-procedure operating room events in VA facilities during 2017, all taking place with no “time out” or a faulty “time out,” with dentistry leading the way in this undesirable statistic among all healthcare practice areas. Had a “time out” been taken here, the mistake would likely have been averted. As with so many aspects of dental practice, proper, timely and clear communication plays an important and indispensable role in avoiding untoward events which often lead to malpractice and the litigation to obtain compensation for it. It cannot be denied that some practices function on the speedy treatment of patients, with the dentists practicing there being pressured to fall in line, but those are the situations most vulnerable to the types of entirely avoidable errors discussed in this case study. A Med-Pro Case Study As the nation’s leading dental malpractice insurance carrier, MedPro Group has unparalleled success in defending malpractice claims and providing patient safety & risk solutions. MedPro is the nation’s highest-rated malpractice carrier, rated A++ by A.M. Best. The Berkshire Hathaway business has been defending dentists’ assets and reputations since 1899 and will continue to for years to come.
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