Cases

• A client claimed her dog was harmed as a result of a medication error. She alleged the dog suffered ‘tick poisoning’ after the practice supplied an inadequate dose of ‘tick prevention medication’. The dose given was calculated on a lower weight range than the dog’s current weight.
• A client alleged his dog died from renal failure as a result of incorrect dosing with an anti-inflammatory agent. The wrong weight had been recorded in the animal’s record. Although the dog was a small breed, a weight of 28kg was recorded. The veterinarian then used that weight to calculate the dosage, without recognising that it was unlikely to be accurate for a dog of that size.
• Guild Insurance also receives a number of similar claims every year where the cause of the incident is difficult to identify. In some instances, the veterinarian simply made a prescribing error and recorded the wrong dose or medication. In others, doses were weaned or titrated incorrectly. That is, a dose was increased when it should have been decreased, or a medication was continued long after it should have been ceased. While many of these errors result in minimal or no harm to the animal, some have had serious consequences. Errors involving prednisolone, NSAIDs or insulin have allegedly caused renal and hepatic failure. Some animals have died.

Tips for practice improvement

• The cases above serve as a timely reminder about just how easily errors can occur. Fatigue, distraction, lack of decision support tools and poorly designed work areas are all recognised as common contributing factors. Therefore, take the time to evaluate your current prescribing and dispensing practices.
  • Are you really doing everything you can to reduce the risk of error? Is your clinical workflow conducive to safe practice?  That is, do poorly designed work areas make it difficult to access things like dosing charts, calculators or product information?
  • Is your prescribing system easy to use and supportive of safe practice?  Have you considered using software with inbuilt alerts to warn you of prescribing errors?
• Always verify an animal’s weight before prescribing or dispensing medication. Weigh the animal at the time and reconcile what’s documented in the record. That is, does the recorded weight seem reasonable for the size, breed and condition of the animal? If it’s not possible to weigh the animal at the time, clarify the recorded weight with the client and again consider what is reasonable for the breed.
• Instruct staff to be particularly careful to double check and dispense the correct size of any medication. For example, 20 mg and 50 mg tablets of some popular NSAIDs may look very similar, but dispensing the wrong ones may cause disastrous consequences.
• Consider the benefits of asking another member of the practice to double check your calculation or selection, particularly if you are working under pressure or fatigued.
• To reduce the chance of inadvertently selecting the wrong medication from the shelf, introduce measures to differentiate between medications that look or sound similar. Ideas include the use of separators and flags, along with avoiding the temptation to store stock in strict alphabetical order.
• Instruct staff to point out all directions on the label and packaging when handing medications to the client. This not only helps to educate them, but serves as a final check against any error.
• Ensure staff always take the time to explain to a client what is meant by using a medication ‘off label’. There have been cases where this has not been explained to the client and they have later complained when they have read the label and seen it is not recommended for their animal.
• Use ‘alerts’ to help distinguish between the records for different animals belonging to the same client. Errors can occur when information, such as weight or test results, are inadvertently entered in the wrong record.
• Promote a culture where all staff are confident to point out risky medication practices when they occur.
• Finally, don’t believe these scenarios couldn’t happen in your practice. While the financial impact can be costly, the impact on your reputation shouldn’t be underestimated. Increasingly, people are choosing not to return to a practice once an error has occurred, instead venting their dissatisfaction via social media and the like.

Download PDF here

Guild Insurance and our claims experience

Guild Insurance regularly analyses its claims data to gain an understanding of the risks faced by dentists insured with us.  This information is then used to create risk messages to assist those dentists to manage their risks.

Guild’s claims data shows that general dentists performing orthodontic treatment are at a high risk of receiving a complaint.  The likelihood of a claim against a general dentist who undertakes orthodontic work is almost twice that for a general dentist who doesn’t do orthodontic work. 

Guild isn’t suggesting general dentists cease orthodontic work.  However general dentists who perform orthodontic work need to have a clear understanding of the risks they face so they’re in a position to reduce the likelihood of those risks becoming a reality.

Expanding your practice

It needs to be acknowledged that whilst the primary concern for dentists is the care of their patients, they’re also running a business.  And any businessperson would be wise to think about how they can improve and grow that business.  However it also needs to be acknowledged that most changes to a business’ operations present new risks which need to be managed. 

One of the key ways the risks of introducing orthodontics into the services being offered by a general dentist can be managed is to carefully consider the training which is undertaken.  As with any CPD, dentists have an obligation to ensure that the orthodontic training they take up is of the standard and quality required.  Not all training will be of the same standard and dentists need to thoroughly research their training options so they select that which is most ideal.  Selecting training simply based on cost, location and convenience is not acceptable, yet unfortunately this does happen.  Dentists need to remember that they’re responsible for any treatment they provide.  Therefore they need to take responsibility for ensuring they’re appropriately trained to provide this treatment.

Understand your level of knowledge and expertise

Whilst all areas of dentistry are in a dentist’s scope of practice, dentists should form their own personal and unique scope of practice.  This requires dentists being honest with themself in terms of their individual level of knowledge and expertise and only performing treatments which fit within this.  Dentists need to know the extent of their ability; this helps to ensure they provide appropriate and safe treatment to all patients. All dentists will have their limitations in terms of what treatments they can and should undertake.  No dentist will be the answer to all dental needs for all patients.

Knowing when to treat and when to refer

This may sound like an unusual message to give to a health professional, however knowing when to NOT treat is incredibly important. 

General dentists who undertake orthodontics have a professional responsibility to identify patients whose clinical situation and treatment need is beyond their scope and expertise.  And once this is identified, these patients must be referred to an orthodontist.  This requires dentists to have an open and honest conversation with the patient explaining why they aren’t able to provide treatment and why they need to see a specialist orthodontist. 

During this conversation dentists mustn’t allow patients to convince them to provide treatment.  It’s not uncommon to hear of cases where a dentist has recommended a referral to a specialist yet the patient hasn’t wanted to take that referral; this may be due to cost, distance to travel or simply that they want to continue treatment with who they know.  Again, dentists are responsible for any treatment they provide.  If the patient suffers a poor outcome following treatment, claiming that the patient requested you carry out the treatment, rather than a specialist, is no defence for poor treatment or clinical decision making. 

Being responsible for treatment provided also extends to situations when the patient has requested particular treatment.  It’s not uncommon for patients to do their own research and then request specific orthodontic treatment from their dentist, rather than wishing to discuss treatment options.  However in these cases the dentist must ensure the patient is thoroughly assessed, has had treatment options explained to them, has given their informed consented to treatment and only receives treatment that is in their best interests.  And of course, a patient requesting specific treatment from a specific dentist doesn’t negate the need to refer when required.

Openness about not being an orthodontist

Guild regularly sees complaints from patients where they claim they didn’t realise that the dentist performing their orthodontic treatment wasn’t an orthodontist.  It’s hoped that in the majority of these cases the dentist hasn’t intentionally misled the patient into believing they’re a specialist when they aren’t, instead the patient has simply made an assumption.  When patients don’t have clinical expertise, making an incorrect assumption is easy to do.  It’s not hard to imagine patients thinking that someone performing orthodontic treatment must be an orthodontist.

Regardless of how a patient forms this view, the dentist must make sure the patient is clear in their understanding.  This means being very upfront and honest with the patient in explaining that you’re a general dentist who is able to perform some orthodontic treatment, but that you aren’t an orthodontist.  It’s also important to make it clear to these patients that they have the option of choosing to see an orthodontist if they wish.  Not suggesting you’re an orthodontist isn’t enough; dentists should be explicit in informing the patient that they aren’t.

In summary…

If a general dentist decides to provide orthodontic treatment, it’s imperative they understand the risks involved and take conscious steps to reduce those risks.  This is likely to lead to better treatment outcomes for patients, which usually leads to satisfied patients who are less likely to complain.

Download PDF here

Sometimes the best treatment a dentist can provide is none at all.

This may sound like an unusual thing to suggest.  After all, a dentist’s job is all about treating patients.  However it’s vital that the treatment provided is performed appropriately and in the best interests of the patient.  To ensure this, there will be times where referring a patient to another dentist, rather than providing treatment, will be the most appropriate course of action.

Understanding your scope of practice

All dentists should develop their own personal and unique scope of practice.  This will be based on what they know they’ve been appropriately trained to do and have the necessary experience in.  It also requires them to be honest and open with themselves regarding their knowledge and expertise.

The next step for a dentist once aware of their own personal scope of practice is to recognise when the required treatment is outside that scope of practice and therefore not something they should undertake.  When the treatment is outside a scope of practice, the patient should be referred to another dentist.

Benefits of referring

Whilst it may at times be tempting to not refer a patient to another dentist as that could be seen as losing business, there are a number of benefits to consider.

By referring a patient to a specialist, you’re providing the patient with what you see to be the most appropriate treatment.  Whilst the outcome of treatment can never be guaranteed, the most appropriate treatment is more likely going to provide the patient with the most appropriate outcome.

Guild Insurance regularly sees claims where a patient has experienced a poor outcome following dental treatment and then requires corrective treatment from a specialist.  It can be argued that in some of those cases, the dentist should have considered referring prior to commencing treatment.  If these poor outcomes lead to a complaint or demand for compensation, the dentist’s clinical decision making and treatment planning may be questioned.

These poor outcomes can also have a detrimental impact on the relationship with a patient.  It’s to be expected that a patient will be disappointed if they experience a poor or unexpected outcome following treatment.  However factors other than the outcome can contribute to or exacerbate this disappointment.  When a patient requires corrective treatment from a specialist, they often question why they weren’t referred to a specialist initially.  This can lead to patients developing a sense of not trusting their dentist due to believing the dentist hasn’t acted in their best interests.  Some patients will even question if the reason for not referring was due to financial greed.  And it’s important to keep in mind that patient’s don’t just complain about clinical outcomes, many also question the behaviour and professionalism of the dentist.

It’s not uncommon for health professionals to feel uncomfortable telling a patient that they can’t perform a particular procedure.  However patients quite often appreciate this honesty and don’t expect a health professional to know and do anything and everything.  Patients will most likely appreciate being informed that there is another dentist who may be more skilled in a particular treatment and that it would be beneficial for the patient to be treated by this other dentist.

Refusing to treat

Sometimes not treating a patient is about more than just a referral and becomes a refusal to treat.  Occasionally patients will be referred to another dentist, yet they don’t want to take up that referral and would prefer to be treated by the dentist they know and trust.  However dentists need to remember that if the treatment is outside their personal scope of practice, they shouldn’t provide it.  If there’s a poor outcome following that treatment, claiming that the patient insisted on it being provided is no justification.  Dentists are always responsible for the treatment they provide and they mustn’t let a patient convince them to treat if they know they aren’t appropriately skilled or trained to do so.

In summary…

Before providing treatment, always stop to consider whether you are the most appropriate person to be performing this treatment and whether the treatment you intend to provide will be in the best interests of the patient.  And remember that referrals can contribute to patient satisfaction and lesson the likelihood of complaints.

Download PDF here