Fall 2018 - Dental Insights

Posted in Dental Insights on Saturday, September 1, 2018

From Dental Insights, Fall 2018

By Linda J. Hay, HelplerBroom, LLC

An "adverse event" occurred … What’s next? 

Every practitioner must know the reporting requirements for adverse events taking place in the state in which they are licensed. 

The statutory provision that requires the reporting generally includes anesthesia events, death, hospitalization or severe injury related to a dental procedure. However, when it comes to defining an adverse event or occurrence, some state statutes are more inclusive, and can encompass temporary events. This is in addition to events resulting in permanent physical or mental injury and those requiring medical intervention as a result of local or general anesthesia. 

The details of exactly what triggers a required report to a state dental board can vary, as can the time to file a report. However, anytime there is a death, medical intervention, hospitalization or serious injury that occurs close to when a dental procedure was performed, the practitioner must immediately investigate the situation. 

For example, some states require notification of serious events, such as a death, be filed as soon as 48 hours after the event. This notification requirement may include situations resulting in hospitalization or emergency treatment. In these instances, some states allow an initial notification to be followed by a complete written report. 

As the investigation must be done promptly, it is critically important to seek assistance from your professional liability carrier or your personal healthcare legal counsel about whether to file a report, as well as the preparation and filing of the report. 

The reports generally require the following information:

• Dentist’s name and license number
• Contact information (email, phone number and address)
• Date and time of the occurrence
• Facility where occurrence took place
• Name of patient, gender and medical history
• Dental procedure involved and the duration of treatment prior to the incident
• Type and dosage of all drugs and medications used in the procedure
• A description of the occurrence and interventions
• The condition of the patient pre-op and post-op

The Reports

The following are three sample reports from our case files that have been brought before dental boards. The names have been changed to protect the identity of those involved. These practitioners were investigated as a result of adverse events from their actions.

Report No. 1

Dentist’s Name and License Number: 
Alexander Rubloff
Dental License Number: 000-000000

Date and Time of Occurrence: 
October 3, 2011, approximately 6:30 p.m.

Facility Where Occurrence Took Place:
West Coast Dental
23 Commerce Drive
Western Grove, US

Name of Patient:
Julia Roper

Dental Procedure Involved:
Extraction of tooth 2 for extensive decay and fracture

The Type and Dosage of Sedation or Anesthesia Utilized in the Procedure:
2 carpules lidocaine with epi at 1:50,000

The Circumstances Involved in This Occurrence:
On October 3, I removed tooth #2 along with some attached bone from the maxillary process. After surgery, there was good hemostasis and a list of sinus precautions was given to her with her routine post-op instructions. A follow-up appointment was set for one week after surgery.

While I was writing Mrs. Roper’s postoperative notes, a staff member noticed that she was blowing her nose. The patient was advised not to blow her nose for several days as this could stimulate post-op bleeding. The patient was checked again prior to discharge, at which time she had adequate hemostasis.

Approximately one hour after discharge, Mrs. Roper called to let me know that she had developed facial swelling and was still bleeding. I advised her to bite down on a wet, black tea bag until the bleeding stops. 

About an hour later, the patient’s husband called to inform me that his wife’s face was still swollen. I asked him to send me a picture via the phone, and after review, I advised him to have his wife place a cold compress on her swollen cheek. The patient’s husband then went to the pharmacy, and upon his return 10 to 15 minutes later, called to inform me that his wife’s bleeding had not stopped, and he was taking her to the Emergency Room. I called and left a message the next morning. 

A doctor from the medical center called me later that afternoon to tell me Mrs. Roper was in ICU with a lateral pharyngeal hematoma. He also informed me that Mrs. Roper’s INR was in the 2.5 range, and although the bleeding was better, it had not completely stopped. He further told me that the patient had been given platelets and that an ENT consult had shown the sinus to be fine.

Report No. 2

Dentist’s Name and License Number: 
Elizabeth M. Shores
Dental License Number: 000-000000

Date and Time of Occurrence: 
March 16, 2012, between 4:00 and 4:30 p.m.

Facility Where Occurrence Took Place:
Shores Dental
1525 Surf Street
Lake Anywhere, US

Name of Patient:
Rosemary Johnson

Dental Procedure Involved:
Extractions of teeth 4, 6, 8, 9, 10 in preparation for dentures

The Type and Dosage of Sedation or Anesthesia Utilized in the Procedure:
1.5 carpules 4% septocaine with 1:100,000 epi.

The Circumstances Involved in This Occurrence:
Due to severely broken down dentition, Mrs. Johnson agreed to have an immediate upper denture placed. At the visit during which the agreement was made, I noted her blood pressure was high, in the 170/90 range. Mrs. Johnson reported to me that she checked her blood pressure regularly, and it normally was in the 120/80 range.

When Mrs. Johnson returned for extractions approximately one week later, she came in with her monitor to show me that it was in the normal range. I noted that before the procedure, her BP was 175/85 in left arm, with pulse of 101 bpm. Her BP in the right arm was 156/82, with pulse of 107 bpm. We provided her with oxygen for 5 minutes, with breathing exercises prior to the 1.5 carpules of 4% septocaine with 1:100,000 epi. 

I performed extractions on teeth 4, 6, 8, 9, 10 without complications. I also placed an immediate denture, gave Mrs. Johnson postoperative instructions and advised her on which over-the-counter medications to take. Mrs. Johnson was pleased and coherent. She was released and proceeded to the front desk to checkout under her own power. 

At checkout she was normal, but as she readied to leave, staff noticed she was disoriented. I called 911 and administered O2 until paramedics arrived. She was taken to the local hospital.

Report No. 3

Dentist’s Name and License Number: 
Martin G. Lincoln
Dental License Number: 000-000000; Specialist License Number: 000-00000

Date and Time of Occurrence: 
August 23, 2012, between 10:30 and 11:00 a.m.

Facility Where Occurrence Took Place:
Dental Offices of Dr. Martin G. Lincoln
2855 66^th Avenue
Anywhere, US

Name of Patient:
Joshua Miller, Minor

Dental Procedure Involved:
Labial Frenectomy
Labial Lingual Frenectomy

The Type and Dosage of Sedation or Anesthesia Utilized in the Procedure:
No anesthesia was used. No local anesthesia and no topical anesthesia.

The Circumstances Involved in this Occurrence:
After history and examination and with parental consent, I performed a labial frenectomy and lingual frenectomy on Joshua Miller using a laser. I completed the procedure without incident in approximately 3–4 minutes while Joshua was laying on his mother’s chest. I used a suction during the entire procedure. 

Joshua became unresponsive after the procedure while I was providing postoperative instructions. A staff member immediately started CPR and I called 911. The ambulance and emergency response team arrived within three minutes and took over care.

Background and Outcomes

Case Report No. 1
With the assistance of counsel appointed by the carrier, the report was filed. The records were requested by and produced to the state dental board. The doctor then appeared before the board with counsel to answer questions about the event. The questioning focused heavily on the failure to use a clotting agent post operatively. 

The doctor presented very well and took the situation seriously. He was asked to enter into an agreed nondisciplinary consent order that required him, within a prescribed timeframe, to take department-approved continuing education courses on oral surgery and medicine. 

The order specifically mentioned the doctor “learned a great deal from this incident and made changes to his practice.” 

Case Report No. 2
The patient was taken to the ER and later released. With the assistance of counsel appointed by the carrier, the report was filed. No action was taken by the department after filing of the report.

Case Report No. 3
The child was resuscitated and taken to the hospital. With the assistance of counsel appointed by the carrier, the report was filed. According to the department and what the doctor later learned, it appeared the child had an undiagnosed congenital heart condition, which was subsequently treated. 

The records were requested, and the doctor appeared at an informal conference with his lawyer. The doctor was well-prepared and made a good witness. He described with specificity not only the details of this event but also the emergency plan he had in place for similar events. Indeed, a month prior to this event, a drill with all staff had been conducted in the office. 

When the actual event occurred, the staff and doctor took action immediately in a well-coordinated manner. These events were noted both in the patient chart and in the paramedic report. Following the conference, no further action was taken.

What Can We Learn?

• Be careful not to speculate or opine on any dental or medical conditions, diagnoses, etiology or causative links concerning the adverse event and the care rendered. It is important to report only on the known facts and the known, pre-event dental diagnoses. Remember that in this type of event, there may be far more, as-of-yet-unknown, facts to consider—whether medical, dental or other. The report requires reporting known facts and details; it does not call for the practitioner to speculate on what happened and why. Most times, the dental practitioner is privy to what transpired in later medical and/or dental care.  

• Know your state dental board requirements! This is particularly true in determining what’s reportable and what isn't. For example, in Case No. 2, it appears that the patient suffered a syncope, was transported to the hospital for observation and was subsequently discharged home without admission. In the state of Ohio, for instance, this likely would not be a reportable case. Every dentist must be familiar with his or her state’s requirements concerning adverse event reporting. 

• Contact your malpractice carrier. It is important to recognize triggering events early, understand the reporting requirements and seek timely assistance. When an event occurs, the second call you should make (after 911) should be to your malpractice carrier. Either saying too much or documenting too little can lead to major problems should subsequent litigation arise.  Early counsel from your malpractice attorney is critical following an adverse occurrence.
  
  An investigation must be done promptly, and notification should be made to your malpractice insurance carrier or your personal healthcare legal counsel. They can help determine whether an event has triggered a reporting requirement, and if so, assist with preparation of the report and timely filing. When serious events occur, there can be considerations beyond the state reporting requirements. 

• Be aware of how your malpractice carrier or your personal healthcare legal counsel can help guide you through the reporting process and its related issues, including: 
  • A potential malpractice claim
  • Communications with the patient, family, law enforcement, other healthcare providers and the media
  • Potential repercussions for reimbursement issues
  • Assistance with law enforcement or other formal investigations 

This case study was written by Linda Hay, J.D. All names used in Dental Insights case studies are fictitious to protect the privacy of the dentist and the patient.

Linda J. Hay is a partner in the Chicago office of HeplerBroom, LLC. Ms. Hay has practiced in the professional liability defense arena for more than 25 years and has tried numerous cases to verdict. She is actively involved in a variety of defense bar, professional liability and risk management organizations. Ms. Hay can be reached at Linda.Hay@heplerbroom.com.