Risks in the routine

IN a number of previous Soundbite issues we have looked at the potential dento-legal pitfalls which are inherent in many aspects of clinical practice. The areas considered have ranged from complete prosthodontics for the edentulous patient to elective cosmetic interventions for those who are fundamentally dentally fit.

The underlying message which I hope has emerged is that dentistry, while extremely important and rewarding, also requires the practitioner to assess and manage a seemingly never-ending series of risks on a daily basis.

Much of this process is mandatory. Ever wondered why rainforests are disappearing? Wait until you are presented with your first practice inspection checklist. Everything from the immunisation of staff to participation in basic life support training must be verified.

Yet, these practical safety requirements, while very important, do not offer a comprehensive mechanism for minimising the possibility of adverse outcomes. Risk management is also applied at a less formal, even intuitive, level and is often a product of application and experience. In fact, many seasoned practitioners will instinctively implement and refine their systems of work as a result of previous incidents and near misses.

To illustrate this point, let’s follow a patient on an imaginary ‘journey’ through a routine dental visit.

At the reception desk

In the first instance, patients will usually go straight to the reception desk. The apparently mundane process of booking in is actually a little minefield. If patients’ initial experience is negative or inefficient, the entire process of persuading them to receive (and pay for) dental treatment becomes that bit harder.

So, in the well-run practice, the receptionists have sufficient support and training so that patients are made to feel they are in good hands from the outset. Even more importantly, their details are accurately taken, ensuring the records uplifted and the medical history completed are correct.

Waiting times

The patient is then usually asked to have a seat in the waiting room. Most reasonable people will not expect to be seen immediately, which is lucky since dentistry doesn’t lend itself to punctuality.

We have all had a tooth which wouldn’t come out, a crown which wouldn’t fit or a child who wouldn’t stop projectile vomiting (long story). However, smart dentists will have considered or even audited waiting times in order to identify and eliminate the most common reasons for running late. They know from bitter experience that, once all of the copies of People’s Friend have been read twice, trouble usually follows.

So, the patient is called into the surgery, more or less on time, to be greeted by a dentist who is furnished with the correct clinical information. So far, so good. The patient is perhaps a little unhappy about the prospect of an imminent dental exam or treatment, but at least the situation hasn’t been exacerbated by delays or administrative errors.

Managing expectations

Assuming that this is a first visit, an essential component of the ensuing consultation will be the clinical history. It may be that the patient will be a motivated, regular attender with low treatment needs. It goes without saying, however, that not every patient will fit this description. Obviously, the ethical practitioner must endeavour to address the needs and expectations of the individual. However, if insurmountable difficulties are identified and managed at the outset, then the risk of disappointment and conflict later on can be minimised.

For example, an edentulous patient may present holding a bag which contains the unsuccessful efforts of several previous practitioners. At this stage, it is only fair to politely explain that these dentures would require to be examined in situ and, if it transpires that they cannot be improved upon, it may not be appropriate to try again.

Patients who are so advised may decide to leave immediately. This outcome, while unpleasant, is probably preferable to the dispute which will follow once the patient has attended umpteen visits culminating in dentures which are no better than the existing ones.

In most instances, the patient will continue with their examination. This does not mean that you are obligated to agree to your patient’s wishes. If a treatment option is contrary to your best judgement, it should not be attempted, irrespective of how desperately it is desired by the patient. Remember, no amount of ‘consenting’ will validate poor dentistry!

Of course, it may be that the treatment is viable, but beyond your ability. In such cases, a suitable explanation, followed by referral to a specialist is not only in the patient’s best interests but might also be an efficient means of transferring the risk away from your practice. It’s worth remembering, however, that an excessive reliance on referrals carries its own risks – you won’t earn and you won’t learn.

Planning and communication

Let’s assume that at the conclusion of the examination a treatment plan is created. The patient’s agreement should be based upon a complete knowledge of what is being proposed, together with risks, alternatives, costs etc. In fact, the GDC now expect all patients to be provided with a written treatment plan and cost estimate. Failure to properly inform patients at the consenting stage can lead to all sorts of problems, both in terms of patient complaints and compliance with regulatory requirements.

In all likelihood, your new patient will need to return for treatment. Here the process of risk management is resumed. The complaint-averse practitioner will confirm that the patient is still cognisant and content with the agreed treatment. The previous notes (which should have been carefully prepared at the previous visit) will be checked and bitewings will be reviewed before any intervention.

As treatment progresses, communication will continue. For example, if a filling turns out to be unexpectedly deep, warn that it may be sensitive post-operatively.

Reassure that this will probably be mild and self-limiting but, if not, you will be happy to provide further treatment. If the tooth is a little symptomatic the next day, the patient will not be on the phone to your receptionist in a state of alarm. If it remains completely asymptomatic, the patient will think you’re a genius (though the tooth is probably non-vital!).

Audit

Finally, a great way of monitoring many of your systems of work is via clinical audit. This activity can effectively gauge aspects of your business such as waiting times or invoicing. It also helps to measure ongoing compliance with formal regulations in terms of, for example, record keeping and IR(ME)R. There can be little doubt that identifying and rectifying departures from efficient and good practice in this way helps to minimise the risk of problems, complaints and investigations. This, in turn, maximises the likelihood of getting a good night’s sleep.

Doug Hamilton is a dento-legal adviser at MDDUS