Recent times have seen a lot of change in dentistry, from which came greater clarity in some areas — Open Disclosure — and greater confusion in others — Scope of Practice.
Open disclosure
No matter how careful, qualified or experienced we are, adverse events are an inevitable part of dental practice. For many years ADA NSW has been writing articles on a practitioner’s obligation to fully inform a patient should something go wrong. So the concept is not new and ‘open disclosure’ is already occurring in many areas of dentistry, but what is new is the Australian Commission on Safety and Quality in Healthcare’s standard and the reference within the Dental Board of Australia Code of Conduct .
Both these references aim to promote a clear and consistent approach by healthcare professionals to open communication with patients and their nominated support person following an adverse event. This includes a discussion about what has happened, why it happened and what is being done to prevent it from happening again. They also aim to provide guidance on minimising the risk of recurrence of an adverse event through the use of information to generate systems improvement and promotion of a culture that focuses on health care safety.
Principles of open disclosure
Open disclosure is the open discussion of incidents that result in harm to a patient while receiving health care. The principles of open disclosure include:
- Openness and timeliness of communication: When things go wrong, the patient and their support person should be provided with information about what happened, in an open and honest manner at all times. The open disclosure process is fluid and may involve the provision of ongoing information.
- Acknowledgment: All adverse events should be acknowledged to the patient and their support person as soon as practicable.
- Expression of regret: As early as possible, the patient and their support person should receive an expression of regret for any harm that resulted from an adverse event.
- Recognition of the reasonable expectations of patients and their support person: The patient and their support person may reasonably expect to be fully informed of the facts surrounding an adverse event and its consequence, treated with empathy, respect and consideration and provided with support in a manner appropriate to their needs.
- Staff support: Dental Practices should create an environment in which all staff are able and encouraged to recognise and report adverse events and are supported through the open disclosure process.
- Integrated risk management and systems improvement: Investigation of adverse events and outcomes are to be conducted through processes that focus on the management of risk. Outcomes of investigations are to focus on improving systems of care and will be reviewed for their effectiveness.
- Good governance: Open disclosure requires the creation of clinical risk and quality improvement processes where adverse events are investigated and analysed to find out what can be done to prevent their recurrence. It involves a system of accountability through the practice principal/senior dentist to ensure that these changes are implemented and their effectiveness reviewed.
- Confidentiality: Policies and procedures are to be developed by a dental practice with full consideration of the patient’s, carer’s and staff’s privacy and confidentiality, in compliance with relevant law, including Commonwealth and State/Territory Privacy and health records legislation.
The open disclosure process
As health professionals, we have a legal and ethical duty to our patients to notify them when things go wrong. A good practitioner will recognise what has happened and;
- act immediately to rectify the problem, if possible, including seeking any necessary help and advice,
- express regret,
- explain to the patient as promptly and fully as possible what has happened and the anticipated short-term and long-term consequences,
- acknowledge any patient or client distress and providing appropriate support,
- comply with any relevant policies, procedures and reporting requirements, subject to advice from a professional indemnity insurer,
- review adverse events and implementing changes to reduce the risk of recurrence,
- report adverse events to the relevant authority as required,
- ensure patients or clients have access to information about the processes for making a complaint.
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. Dental practitioners need to be aware of the risk of making an admission of liability during the open disclosure process. In any discussion with the patient and their support person during the open disclosure process, the dental practitioner should take care not to:
- state or agree that they are liable for the harm caused to the patient
- state or agree that another health care professional is liable for the harm caused to the patient
- state or agree that the dental practice is liable for the harm caused to the patient
Case studies
The following case studies emerged from a search of DDAS files for incidents which involved a decision on whether to inform the patient of a problem. Whilst the search was a purely random one, you will see that in every instance no action was taken by the patient. Whilst not necessarily illustrated by all of the examples below, a policy of open disclosure can help to build patient trust and in many instances, results in a positive change to practice procedures thereby improving patient care.
Caries overlooked
Case details: Tooth 45 requires RCT as a result of a cavity not being detected on the x-ray two years ago. Patient has had an exam 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 afterward. 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 for no charge. A good relationship was maintained with the patient who had loyally attended this particular practitioner for 15 years, including following her through three changes of practice location.
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.
Wrong filling replaced
Case details: The family had been attending a dental practice for 8 years. One of the adolescent members of the family, with a history of high caries, had fillings placed on 26 and 37. A couple of months later a filling in 47 was to be carried out due to recurrent caries. Unfortunately the practice manager wrote the wrong tooth number on the patient’s card, the dental nurse took a digital x-ray for tooth 37, and when the patient attended for treatment, the dentist removed the 37 filling to find no decay, at this point realising 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 for no charge. 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 and it is clearly incumbent on him/her to check that the right tooth is about to be treated before commencing any dental procedure.
Perforation during root canal therapy
Case details: 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 with an Endodontist was recommended should the patient wish to continue with the treatment. 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 who 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, and reminding her of their detailed discussion about the problems with, and treatment options available for, tooth 46 at a visit prior to the RCT appointment. 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 heard nothing in reply and the patient had failed to take up the offer of refund. The RCT was completed by the E ndodontist 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 and 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, and about which the patient should be warned 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 on 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.
Wrong tooth filled
Case Details: 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. 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 3 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, and 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.
Comment: 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 to avoid a similar error recurring.
Clinical privileging
In the last six months, how many times have you heard another dentist state that his/her hygienist is able to perform procedures that your hygienist doesn’t. Equally so for a therapist or Oral health therapist. And you wonder how they can “get away with it”. With the introduction of the National Law, many of the state based differences could not be maintained and specifically defined as previous. The scope of practice for Dental hygienists, dental therapists and oral health therapists is one such area.
Dental hygienists, dental therapists and oral health therapists exercise autonomous decision making in those areas in which they have been formally educated and trained. They may only practice within a structured professional relationship with a dentist. They must not practise as independent practitioners. They may practise in a range of environments that are not limited to direct supervision
— Dental Board of Australia Scope of Practice Standard
There is no longer a blanket descriptor for each of the roles. The onus is now firmly on the dental practitioner to assess their own competency and perform only those procedures for which they have been formally educated and trained in programs of study approved by the Board. The pursuit and development of additional skills will then raise some legal considerations that must be addressed in the context of the broad range of patient care for which the dental practitioner is legally accountable. It will undoubtedly be the obligation of the practice principal/senior dentist to ensure that the right people have the right education to provide the right procedure within the practice- clinical privileging.
By David Sweeney (ADANSW)