Management of Treatment Complications

By Sue Wilson, MBA, CPHRM, Patient Safety Risk Manager, The Doctors Company

Even when a patient is provided with care that meets the standard of care, complications may arise during, or as a result of, the treatment provided. It often is helpful to review this type of case to determine not only the root causes, but also how the complication was managed.

Case Study
A patient presented to a dentist for evaluation of tooth extraction and fitting of dentures. During the extraction, the patient complained of extreme pain and allegedly stated it felt as if the jaw had been broken.

The patient was discharged home and returned the following day complaining of pain, and presented with a swollen and bruised jaw.

A dental X-ray revealed a compound fracture of the left mandible. The dentist referred the patient to an oral surgeon, with a letter outlining the X-ray results and information about when the fracture may have occurred. The oral surgeon diagnosed a left displaced mandible fracture and admitted the patient to the hospital for surgical repair. The following day an open reduction internal fixation (ORIF) was performed and the patient was discharged a day later.

Subsequently, the patient developed complications and required several additional surgical procedures. The patient alleged the dentist was negligent in failing to properly document the extraction procedure, failed to maintain proper medical records, failed to take adequate pre-extraction X-rays, applied excessive force during the extraction that resulted in the fracture and failed to adequately assess the patient’s complaint by immediately obtaining an X-ray. The plaintiff’s expert dentist affidavit opined the dental care was below the standard of care and directly caused the subsequent injury and complications. Medical records from subsequent treating professionals revealed the patient continued to have pain, loss of jaw function and became anorexic as a result of inability to chew properly. The case was settled.

Documentation
It’s widely understood that health care records should contain a complete assessment of prior dental, medical, surgical and pharmaceutical history. However, there often is confusion about how to document complications or complaints. It’s important to objectively describe any complaint or complication arising during or following a procedure, as well as the assessment and actions taken in response to the complaint or complication. In this case, when the patient complained of pain, the dentist did not stop to determine the source or severity of pain and did not obtain an X-ray post treatment. Although the dentist stated in a letter to the oral surgeon he suspected the fracture occurred following extraction of a specific tooth that was ankylosed, he did not document the same in the patient’s record, nor did he document discussions with the patient following the procedure.

Recordkeeping
When a request is received for records and X-rays, a complete copy should be made and the originals retained in the office. In this situation, all original X-rays and medical records were given to the patient without keeping a copy, making it difficult to determine what was documented by the dentist and staff. When referring to another care provider, provide a copy of the medical records and X-ray films, but the original records and films should be kept and it should be documented that a copy was sent to the treating provider or given directly to the patient.

Communication
Maintaining communication with the patient and other treatment providers is essential. In a study of plaintiffs who were asked why they chose litigation against their health care provider, most responded they were seeking an apology and an explanation. It’s important to provide both to a patient who is potentially or actually injured. However, in many cases the cause of injury or complication is not known right away; therefore, it’s equally important not to assume blame, or to point to others as the cause of complication or injury.

Consult with Your Insurance Provider
When an adverse outcome resulting in potential or actual harm occurs, it should be discussed with your insurance company representative as soon as possible. In this case, the event was not reported until the patient requested her medical records and retained an attorney. At The Doctors Company, there are claim specialists and patient safety risk managers who can assist with communication, documentation, legal and regulatory questions and, if appropriate, compensation to the patient. Seek guidance from a patient safety risk manager or claim specialist before financial arrangements and agreements take place in connection with an undesired outcome, complication or injury.

Although zero injury is the goal, when an undesired outcome, actual injury or serious complication does occur, it often is how it is handled that determines the outcome for both the patient and the health care provider.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Reprinted with permission. ©2018 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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