Summary
Practices that proactively implement well-designed policies and procedures can prevent harm, improve patient outcomes, and reduce the potential for an adverse event.
It was a busy Monday morning for Dr. Johnson*, a general dentist in a group practice. His schedule was packed with patients, and a few emergency appointments had been added on during the day. Amid this heightened activity, a 41-year-old woman with progressive dental caries arrived for extraction of two lower molars (numbers 18 and 19).
Soon after Dr. Johnson completed the extractions, the patient realized that he had mistakenly removed a healthy tooth (number 20 instead of number 18) and brought it to Dr. Johnson’s attention. The doctor immediately recognized and apologized for this mistake, then extracted the correct diseased tooth. Ultimately, the patient required an implant to replace the healthy tooth that was mistakenly removed.
Though Dr. Johnson completed the subsequent procedures without further incident, the patient had to endure the pain and inconvenience of additional dental procedures, extended recovery time, and missed time from work.
A wrong tooth extraction (WTE) is a significant medical error and can result in a dental malpractice claim. WTEs can result in negative repercussions for the patient, such as pain, bleeding, nerve injury, and psychological issues. These events can also result in reputational damage to the dentist and practice, psychological distress for practitioners and staff, and monetary loss. Risk management issues that commonly contribute to WTEs are miscommunication, incomplete or unclear referrals, inaccurate review of the patient’s dental record, poor policies and procedures, and overscheduling.
Your organization can prevent WTEs by mastering effective communication skills and implementing proactive risk management strategies. Consider the following when reviewing your tooth extraction policies and procedures:
WTEs can cause disruption and stress for patients, dentists and staff. Practices that proactively implement well-designed policies and procedures can prevent harm, improve patient outcomes, and reduce the potential for an adverse event.
* The case study presented in this article is fictional. The characters, events and situation contained in the case study are not based on real individual or incidents.
Soon after Dr. Johnson completed the extractions, the patient realized that he had mistakenly removed a healthy tooth (number 20 instead of number 18) and brought it to Dr. Johnson’s attention. The doctor immediately recognized and apologized for this mistake, then extracted the correct diseased tooth. Ultimately, the patient required an implant to replace the healthy tooth that was mistakenly removed.
Though Dr. Johnson completed the subsequent procedures without further incident, the patient had to endure the pain and inconvenience of additional dental procedures, extended recovery time, and missed time from work.
A wrong tooth extraction (WTE) is a significant medical error and can result in a dental malpractice claim. WTEs can result in negative repercussions for the patient, such as pain, bleeding, nerve injury, and psychological issues. These events can also result in reputational damage to the dentist and practice, psychological distress for practitioners and staff, and monetary loss. Risk management issues that commonly contribute to WTEs are miscommunication, incomplete or unclear referrals, inaccurate review of the patient’s dental record, poor policies and procedures, and overscheduling.
Risk Recommendations
Your organization can prevent WTEs by mastering effective communication skills and implementing proactive risk management strategies. Consider the following when reviewing your tooth extraction policies and procedures:
- Communicate effectively. Ensure proper communication between the dentist, the referring practitioner, and the patient to confirm which tooth/teeth will be extracted and the reason for the extraction. Document all practitioner/practitioner and patient/practitioner discussions regarding the proposed treatment in the dental record.
- Clarify referrals. Incomplete or unclear referral details can lead to errors, including WTEs. Communicate directly with the referring dentist when the proposed treatment lacks clarity.
- Review the dental record. Carefully review the patient’s dental record and radiographs to verify the tooth/teeth to be extracted. Note unusual dentition and missing or shifted teeth and confirm with an examination. Verbally confirm the tooth that is to be extracted with the patient. Consider using a hand-held mirror so the patient can visually confirm which tooth/teeth will be extracted.
- Obtain consent from the patient. Utilizing plain language techniques, explain the procedure to the patient and ensure that they understand the risks, benefits, and alternatives to the proposed extraction and consents to the procedure. Document the informed consent discussion in the patient’s dental record. Obtain the patient’s informed consent that identifies the specific tooth/teeth to be extracted or treated and capture the patient’s signature on the informed consent form. Include the completed, signed consent in the patient’s dental records.
- Develop a protocol designed to prevent wrong-site surgery. Develop and implement a policy to prevent WTE, a type of wrong-site surgery, utilizing principles from The Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. Include the following components in your protocol:
- Follow a preprocedure verification process. Prior to each procedure, verify the patient, procedure, and procedure site. Include the patient in the verification process. Review the dental record, including medical history, laboratory findings, and dental radiographs. Ensure radiographs are oriented properly when viewing them.
- Mark the procedure site. The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery includes a process for surgical site marking. However, marking teeth for an extraction is impractical. Instead, confirm that the correct teeth and/or tissues have been noted in the record. Indicate the tooth number or mark the surgical site on the diagram or radiograph and include it in the patient record.
- Perform a timeout. Designate a team member, typically the dentist, to start the timeout. Immediately before the procedure, conduct the timeout to verify the patient, tooth, and procedure. Address all questions or concerns prior to initiating treatment. Ensure the timeout involves interactive verbal communication with team members and the patient, if possible. Document the completed components of the timeout in the patient’s record.
- Revise schedules. A heavy workload creates stress and fatigue, which can increase the risk of mistakes, including WTEs. Consider adjusting the dentist’s schedule when necessary.
- Documentation. Accurate, complete documentation is the best evidence of the care provided to a patient. Thorough documentation of the measures taken to prevent WTEs assists in the defense of improper treatment allegations.
WTEs can cause disruption and stress for patients, dentists and staff. Practices that proactively implement well-designed policies and procedures can prevent harm, improve patient outcomes, and reduce the potential for an adverse event.
* The case study presented in this article is fictional. The characters, events and situation contained in the case study are not based on real individual or incidents.
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.