To tell or not to tell
No matter how careful, qualified or experienced we are, errors or acts of misadventure are an inevitable part of dental practice. When harm occurs, it can often be as distressing for the practitioner to deal with as it is for the patient.
During our working lives, many of us will have encountered, or will be faced with the difficult task of informing the patient of an untoward event which has happened, even if it is a recognised complication of a particular procedure. Often the difficulty lies in knowing exactly what to say to the patient. On other occasions, the more fundamental question arises of whether to inform the patient at all. Do they really need to know? What will they think of my competency? Will a complaint be made to the Dental Board or will it even result in a law suit? Will they tell the neighbourhood and ruin my reputation and that of my practice? These are some of the thoughts and fears which may run through our minds.
As health professionals, we have a legal and an ethical duty to notify our patients when things go wrong. "Open disclosure is a frank discussion with a patient and/or their support person(s) about incidents that result in unintended harm or injury to the patient while receiving health care" (NSW Health). The principles of open disclosure include:
- a factual and timely explanation of what happened
- why it happened
- the action being taken to manage the incident and prevent its repetition
- a suitable expression of regret/apology and
- the discussion should take place in a confidential setting (National Open Disclosure Standard).
It is important to note that an explanation of the facts is different to, and certainly should not be, an admission of liability, the latter being statements made by the practitioner indicating direct acceptance of all responsibility for the adverse outcome which has occurred.
The following case studies emerged from a search of Dental Defence Advisory Service (DDAS)* files for incidents which involved a decision as to whether to inform the patient of a problem. Whilst the search was a purely random one, you will see that in every instance (and likewise in other case studies presented in a future article), no action was taken by the patient. Although not necessarily illustrated in the examples below, a policy of open disclosure can help to build patient trust. Plus, in many instances it can result in a positive change to practice procedures, thereby improving patient care.
Case 1. Caries Overlooked
Initial notification: Tooth 45 requires RCT as a result of a cavity not being detected on the x-ray two years ago. The patient was examined by a partner in the practice in between times (no x-rays) and the cavity was also not detected. A crown may also be required.
A patient presented for emergency treatment of severe toothache emanating from tooth 45. RCT was commenced. On subsequent review of the patient's records, the dentist discovered that there had been undiagnosed distal root caries on 45 visible on bitewings taken 15 months earlier. The caries had also not been detected during a dental examination undertaken by a partner in the practice some months later.
Rather than attempt to cover up the oversight, the treating dentist accepted responsibility and wished to correct the error. The patient was informed of the caries and the RCT was completed at no charge. A good relationship was maintained with the patient who had loyally attended this particular practitioner for 15 years, which included following her to three changes of practice locations.
Comment:
Radiographs are one of a dentist's most important diagnostic tools (and can contribute significantly to the defence, or lack thereof, of a claim). On a busy day in a busy practice, occasional oversights are bound to occur. Having a systematic order of examining structures on a radiograph reduces this risk, as does rechecking radiographs at the end of the appointment at which they are taken.
Case 2. Wrong Filling Replaced
Initial notification: An adolescent had fillings placed on two molars. A couple of months later a filling was to be carried out on an additional molar. Due to an administration error, Dr A removed the filling in the incorrect tooth. On finding no decay, it was realised that it was the wrong tooth. Dr A informed the patient and her mother. She wishes to log this as a precaution.
A family had been attending a dental practice for eight years. One family member, with a history of high caries, had fillings placed in teeth 26 and 37. A month later, a filling in 47 with recurrent caries was to be replaced. Unfortunately the practice manager wrote the wrong tooth number on the patient's card so the dental nurse took a digital x-ray for tooth 37. As a result, when the patient attended for treatment, the dentist removed the 37 filling to find no decay. At this point the dentist realised that the wrong tooth had been worked on. The dentist explained to the patient and her mother that she had just redone the filling in tooth 37 by mistake instead of replacing the one in tooth 47. Naturally, there was no charge for the treatment. The filling in 47 was also subsequently replaced at no cost. The dentist's prompt and honest disclosure was rewarded by the patient's calm acceptance of the error and the family's continued attendance at the practice.
Comment:
When multiple members of the dental team are involved in providing treatment, the risk of error increases. Good communication and a system of cross-checking is necessary to avoid perpetuation of errors. The individual practitioner, however, is ultimately responsible for the treatment provided. Therefore, it is clearly incumbent on him/her to check that the right tooth is about to be treated before commencing any dental procedure.
Case 3. Perforation During Root Canal Therapy
Initial notification: Dr B commenced RCT and during the treatment he perforated the root. At the time the patient was advised and the option to see a specialist was given. The patient declined. The following day the patient experienced a lot of pain and saw another dentist who adjusted the temporary filling, provided a script for antibiotics and referred the patient to an endodontist. The patient has written to Dr B outlining her concerns with his treatment.
A patient presented for emergency treatment of pain on the lower right side of her mouth. The dentist commenced RCT on the deeply filled 46, during which he perforated the lateral wall of the mesial root. This was confirmed radiographically. The tooth was dried and dressed, and it was explained to the patient that the perforation had occurred and had reduced the prognosis for long-term retention of the tooth. An endodontic consultation was recommended, should the patient wish to continue with the treatment. Fortunately, the patient was not too concerned and was more interested in having the tooth extracted and a bridge placed. She declined specialist referral. After further discussion, the dentist suggested that she consider what had been discussed before making a final decision on the future of the tooth.
The following day the patient experienced severe pain and attended another dentist at the practice. This practitioner adjusted the temporary filling, provided a script for antibiotics and analgesics, and referred the patient to the endodontist. One month later, the patient wrote to the practice principal accusing the assistant dentist of being 'negligent in his treatment' of her. She stated that she had 'not been given any antibiotics or painkillers by him, the temporary filling had not been completed properly, and he should not have commenced RCT if he was not capable'. She advised that she would be continuing treatment with the endodontist.
The original treating dentist sent a courteous letter of reply to the patient outlining how the perforation had come about and been addressed. This communication also reminded her of their detailed discussion at a visit prior to the RCT appointment about the problems with tooth 46 and the treatment options available. As a result of those discussions, it had been agreed that although the tooth may have to be eventually extracted, they would attempt to salvage it with RCT. The patient had been informed that no guarantees could be given and that there was a failure rate of around 10%. The dentist ended by saying that he was nevertheless happy to offer the patient a full refund ($200) for the treatment he had provided to 46 because of the unfortunate outcome and his primary concern for the satisfaction and wellbeing of his patients. Five months later, the dentist had still not received a reply and the patient had failed to take up the offer of refund. The RCT was completed by the endodontist and the patient was apparently happy with the service that had been provided. A crown was planned to be placed in the near future by another dentist at the practice.
Comment:
A patient will commonly accuse a dentist of 'negligence' however negligence is a legal concept which must be determined by a court of law. With the exception of prima facie examples such as extraction of the wrong tooth, negligence can be very difficult for a patient to prove. It is important to note that comparatively few adverse incidents in dentistry are ever deemed to be 'negligent'. More often, they would be considered as unexpected, but always possible complications of the procedure being performed which the patient should be warned about before the procedure is commenced.
Perforations are more common when treatment has been carried out in an emergency appointment when staff can be rushed and unprepared. When a perforation occurs, it can be tempting to hide it by not taking adequate radiographs which would assist in demonstrating the problem. However by doing so, this may only delay its discovery (often by a future practitioner) when the uncomfortable truth inevitably comes out.
It was fortunate in this case that the perforation did not render the tooth unsalvageable. The outcome was assisted in part by both the dentist's prompt admission of the problem and specialist attention at an early stage. It is important to follow up patients who have been referred to ensure that they follow through with care.
A patient who was well-informed prior to treatment plus a well-worded letter of explanation and genuine expression of regret were important in preventing this matter from escalating.
Case 4. Wrong Tooth Filled
Initial notification: Dr C prepared a tunnel preparation on tooth 27 as seen on the x-ray presented to him. Unfortunately, the x-rays were mixed up and in fact tooth 27 did not require a restoration. When the correct x-ray was located, tooth 26 had a carious lesion. Dr C has not told the patient yet but realises that he must do so. He is seeking advice on management of the situation.
A set of bitewings taken as part of a routine examination on a young adult revealed that a filling was required in tooth 27. At the treatment appointment three weeks later, the dentist carried out a tunnel preparation on the tooth. When no decay was found upon drilling to the depth indicated by the x-ray, it was discovered that the x-rays had been accidentally mixed with nearly identical bitewings of a similarly-aged patient. This meant that tooth 27 did not in fact require a restoration. When the correct x-ray was located, a distal carious lesion was noted in tooth 26.
Upon contacting the DDAS for advice, the dentist was advised to phone the patient and apologetically admit the error and advise of the need for the restoration in tooth 26. If the patient allowed the opportunity for the filling to be placed, it was suggested that it be done for no charge as a goodwill gesture.
It was a difficult call and when it came to the crunch, the dentist opted simply to inform the patient that he had missed a filling and that another appointment would be needed. When the patient presented for treatment, he made no enquiries about the need for the extra filling so the dentist offered no explanations. The treatment was provided for no fee and the patient left happy.
Comment:
It is often very difficult and embarrassing to admit errors to patients and it can be tempting to want to hide them. What distinguishes us as professionals is our management of errors when they happen. Whilst Dr C may have 'gotten away with it' (for now), his management would be considered in breach of professional ethics. In addition, it is important to note that whilst an error or bad outcome is not necessarily negligence, failure to disclose it can be, and can be the basis for a successful claim. Hence the recommendation is always to be transparent with the patient, as difficult as that may be in such circumstances. On a positive note, the dentist amended his procedures so that x-rays are now labelled immediately in order to avoid a similar error recurring.
Key Learnings
Honesty Is The Best Policy If something untoward occurs during treatment, inform the patient and assure him/her that you will work together to rectify the problem.
You may wish to schedule a separate appointment to discuss the issues in detail. This will also allow you time to rethink the treatment plan, seek advice from colleagues if necessary, and prepare for your discussion with the patient. An honest and apologetic approach coupled with a willingness to assist the patient to deal with the issues can greatly assist with defusing any negative emotions which the patient may initially express. This can avoid a claim being pursued.
If remedial treatment is required, discuss the options of carrying it out yourself (if you feel confident and competent to do so) and/or provide a referral elsewhere. Leave it to the patient to decide which path to choose. It is desirable that cost is eliminated as a factor in this decision. Offers of financial assistance, when appropriate, often help minimise any friction with the patient.
For your own protection, other than in simple situations, consult the DDAS, your association or insurer for advice prior to making any such offers. It may be prudent to follow up your discussions with a letter to the patient. Of course you should document your management of the problem and all discussions with the patient in your records, and in a level of detail which is commensurate with the level of complexity of the incident.
If you are unsure of what to say to the patient or are having difficulty in coming to a prompt resolution with him/her, contact the DDAS, your association or Guild for assistance. Take advantage of the opportunity to seek confidential advice from the DDAS, your association or Guild who have dealt with many similar incidents before and are there to provide immediate reassurance and support.
Remember honesty is the best policy. The patient's response may well be better than you fear...
* In 1999, the ADANSW established the Dental Defence Advisory Service (DDAS) to act as the first point of contact for members who are confronted by professional indemnity (PI) complaints, claims or potential incidents.
The Dental Defence Advisory Service (DDAS) ADA NSW
