Legal/Risk Management – Beyond the Bite

Latex Precautions in the Dental Setting

by Florida Dental AssociationApril 20, 2017May 30, 2017Leave a comment

By Rosanne Cain, BSN, LHRM, Patient Safety/Risk Manager II, The Doctors Company

Recognizing latex allergies is an important patient safety precaution.

A 43-year-old registered nurse presented to his dentist for a regular teeth cleaning procedure. After several years of daily use of latex gloves and medical supplies, he developed a severe sensitivity to latex that ultimately resulted in anaphylactic reactions to most latex exposures.

Prior to his scheduled appointment, he contacted the dental office and informed the staff about his severe latex allergy. The dental staff made a note in his dental record and prepared the exam room with nitrile gloves. When he arrived, the dental hygienist recommended protective eyewear. The patient asked the hygienist if the foam cushioning around the eyepieces was latex-free. The hygienist could not confirm. The hygienist also failed to note that she placed small rubber bands, which also contain latex, around the handles of her dental instruments.

The hygienist began the procedure. The patient began to itch, which was quickly followed by wheezing. The procedure was stopped, and the patient immediately administered his medication. The patient’s action avoided a severe anaphylactic reaction.

Discussion
During the past 30 years, latex allergies have been recognized as a significant problem for both specific patient and provider populations. The incidence of latex allergy in the general population has been estimated to be between 1 and 6 percent. Some adolescents experience incidences as high as 73 percent (notably those individuals with spina bifida and related pathologies). Women account for approximately 70 percent of latex-related anaphylactic reactions (most commonly during ob/gyn procedures).¹ Adults with spinal cord trauma, neurogenic bladder or documented history of unexplained intraoperative anaphylaxis also can be affected by frequent exposure to latex supplies. Health care workers maintain an incidence of allergic response that ranges from 8 to 17 percent.² Other at-risk populations with repeated exposure to latex gloves include lifeguards, emergency responders, law enforcement professionals and cosmetologists.

In addition, glove powder has been shown to aerosolize latex proteins and increases the risks of a reaction in latex-sensitized patients or staff. The U.S. Food and Drug Administration recently announced a ban of the use of powdered gloves in surgery, powdered patient examination gloves and absorbable powder used on surgical gloves. The ban was issued after an investigation determined that the powdered products present an “unreasonable and substantial risk of illness or injury, and that the risk cannot be corrected or eliminated by labeling or a change in labeling.”³

Although most dentists are familiar with latex allergies, the infrequency of a severe reaction during a dental procedure can cause inadequate precautionary measures in a dental practice. Implement the following risk management strategies to reduce latex-related risks.

Risk Management Strategies

Know your patient’s latex allergy status, and note it prominently in the patient’s medical records. Allergy status should be updated on each patient visit.
Remove toys that contain latex from your practice’s common areas and play zones.
Practice latex avoidance precautions. Create a patient area that is latex-free and educate staff about all dental-related products that are restricted from the room.
Identify dental products that contain latex, including gingival stimulators, irrigation tips, dental dams, bulb syringes, cushioned eye protection goggles, tourniquets, rubber stoppers on medicine vials, adhesive tapes and bandages, water tubing, prophy cups, and rubber toothbrush heads and grips.
Use latex-free carts, bandages, reservoir bags, airways, endotracheal tubes, laryngeal mask airways and ventilator bellows.
Maintain a list of latex-free dental devices and office products and ensure that it is readily available for staff reference.
Remember that touching any latex object can cause transmission of the allergen by hand to the patient.
Ensure that your supplies include emergency medications with non-latex syringes and medicine stoppers.
Perform practice drills with your staff so they are prepared for latex-related medical emergencies.

For a free brochure on latex allergy, contact the American College of Allergy, Asthma and Immunology (ACAAI) by calling toll-free 800.842.7777. Additional information is available on the ACAAI website at http://acaai.org/allergies/types/skin-allergies/latex-allergy.

References:
1. Allergic reactions during labour analgesia and caesarean section anaesthesia. Adriaensens, I., Vercauteren, M., Janssen, L., Leysen, J., Ebo, D. International Journal of Obstetric Anesthesia 2013 Jul; 22(3): 231-242.

2. American Latex Allergy Association, http://latexallergyresources.org/statistics

3. FDA Rule, Banned Devices; Powdered Surgeon’s Gloves, Powdered Patient Examination Gloves, and Absorbable Powder for Lubricating a Surgeon’s Glove, 81 FR 91722, December 19, 2016, https://www.federalregister.gov/documents/2016/12/19/2016-30382/banned-devices-powdered-surgeons-gloves-powdered-patient-examination-gloves-and-absorbable-powder

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 health care 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.

Case Study: Unethical Treatment Leads to Lawsuit and Dental Board Action

by Florida Dental AssociationAugust 11, 2016May 30, 2017Leave a comment

By Kim Hathaway, MSN, CPHRM, CPHQ, Patient Safety Risk Manager, Department of Patient Safety and Risk Management, The Doctors Company

A celebrity dentist performed excessive treatment and committed ethical violations.

A 46-year-old male was evaluated by a general dentist, who conducted an examination with X-rays. The dentist determined that two dental surfaces were decayed and one tooth had a possible fracture. Excessive wear to the teeth was not indicated, and pretreatment photographs revealed good stippling of the gums.

Five days later the patient presented to a celebrated dentist who practiced general dentistry with advanced training in cosmetic procedures. The dentist was widely known through appearances in multiple television commercials, coverage on reputable news channels and his website. This media exposure created an assumption by the patient that the dentist’s professional qualifications were undeniable.

According to the patient, this publicity was a determining factor for his selection of the celebrated dentist to continue his treatment. During the initial evaluation, the patient complained of a “gummy” smile, as well as chipped and discolored teeth. The dentist performed restorative procedures that resulted in patient fees of $47,000.

A review of the dental record indicated that medical history, initial examination, X-rays and photographs had been repeated by the celebrated dentist prior to treatment. According to the second assessment, the patient had decay on 45 dental surfaces, tooth fractures on 77 surfaces and 31 teeth worn down by one-third to one-half. Gingival recession and tetracycline staining also were noted.

Although the diagnosis and treatment plan were vastly different from those of the original dentist, the patient agreed to undergo the procedures. Following the restoration, the patient remained unhappy with his appearance and experienced unrelenting pain. The pain led to gum surgeries, multiple root canals and significant weight loss. As a result, the patient was ultimately examined by five additional dentists. All of these dentists agreed the procedures performed by the celebrated dentist were below the standard of care. The estimated cost of the examinations by the additional dentists totaled $63,000.

The patient pursued a claim against the celebrated dentist, resulting in an indemnity payment.

A complaint also was issued by the state’s dental board. According to the complaint, the dental record indicated a recommendation of crowns to nine teeth, veneer treatment on 11 teeth, laser treatment on six teeth, a bridge on three teeth and one implant. Other procedures also were performed, including laser treatments to restore the patient’s smile.

Diagnostic imaging and other pretreatment photos did not support the need for restorations. Some teeth that had been diagnosed with decay and/or fractures were not treated. There were other accusations of ill-fitting restorations on multiple teeth.

The complaint contained ethical declarations, including that the dentist failed to address the patient’s concerns appropriately when he complained of pain. The dentist incurred charges of unprofessional conduct, excessive treatment and repeated acts of negligence. The dental board determined that the dentist provided substandard care that was indefensible, unnecessary and incomplete. The allegations were compounded because it appeared the dentist had rewritten a portion of the chart and that critical evidence had been destroyed. This rendered the dentist unreliable in his own defense.

Risk Management Discussion
According to the American Dental Association’s Principles of Ethics and Code of Professional Conduct (ADA Code), “The dental profession holds a position of trust within society.” The celebrity status of the dentist and the media coverage displayed on the dentist’s website indicated to the patient that he could rely on this dentist and trust him more than other dentists. The dentist violated each of the five fundamental principles of the ADA Code: patient autonomy, non-maleficence, beneficence, justice and veracity.

The following strategies can help you avoid unethical allegations:

Understand and practice under the ADA Code.
Provide only tests and treatments that are reasonable and necessary, with documentation to support the necessity of services provided.
Research and follow state regulations related to advertising as well as regulations regarding all aspects of a dental practice.
Exercise caution in advertising to avoid false or misleading claims about treatments, experience, certification or credentials that might misinform patients about the qualifications of a provider.
Display your credentials clearly and accurately. General dentists who perform complex prosthodontic or periodontal treatments, or practice as experts or specialists may be held to a higher standard of care than general practitioners.
Do not alter or destroy the patient record. In the event of a claim or litigation, the alteration will likely be perceived as a deliberate act to deceptively reflect care or explain a less than perfect outcome. Altering the patient record also may result in a regulatory agency disciplinary action and create lasting reputational damage. Concealing damaging evidence will render a case indefensible.

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 health care 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.

Case Study: Documentation and Scope of Practice Issues

by Florida Dental AssociationJune 2, 2016May 30, 2017Leave a comment

By David O. Hester, FASHRM, CPHRM, Director, Department of Patient Safety and Risk Management

Obtaining written and verbal informed consent and patient response to follow-up care are crucial steps to improve patient safety and mitigate risk in your practice.

The patient, a 52-year-old female, contacted her dentist and stated that she had two broken teeth. Upon examination, the dentist recommended the removal of what remained of the broken teeth. The surgery was performed the next day to remove the teeth. The patient was discharged in good condition. The dentist did not have the patient sign an informed consent form prior to the procedure. The dentist later testified that he explained possible complications to the patient. However, the dental record did not include documentation confirming the verbal informed consent discussion. The day after being discharged, the patient called the dentist’s office and reported extreme pain at the surgical site. She requested to speak with the dentist but was told that the dentist was unavailable. She asked for an appointment, but was informed that the earliest appointment would be in five days.

The receptionist did not document the phone call and the patient testified that she was instructed by the receptionist to “just take some Tylenol.” The patient sought treatment from a second dentist. An examination by the second dentist determined that root tips had been left in place during the procedure and deep infection had occurred at the surgical site. The patient required further surgery and antibiotics to fully recover.

The patient pursued a claim against her original dentist.

Risk Management Discussion
An allegation of improper performance of a procedure is a common source of dental claims. The original dentist did not obtain a signed informed consent form. In addition, the dental record did not note that possible complications from the surgery were discussed with the patient. In this case, the original dentist did not remove all of the root tips, which caused pain and the need for additional surgery by a second dentist. The case was further complicated by the lack of policies and protocols to ensure all office staff follow guidelines within their scope of practice and job responsibilities. Guidelines are crucial to correctly triage inquiries to the appropriate staff member and/or the dentist for a timely response to the patient.

The following steps can help you improve quality and mitigate risk:

Explain the proposed treatment, expected results and potential complications to the patient. Have the patients explain what he or she expects from the proposed treatment.
Document all verbal discussions regarding the treatment plan in the dental record, including confirmation that the patient provided verbal understanding.
Develop policies and protocols that guide staff to ensure the timely follow-up of patient inquiries.
Ensure that all staff members document in the dental record telephone calls received from patients.
Educated all staff members and develop policies that ensure they do not practice outside of their license, expertise or scope of practice.

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 health care 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.