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.

Altering Dental Records Can Result in Significant Penalties

By Jon M. Pellett, JD, Managing Attorney – Administrative Defense, Medical Investigation Defense Unit, The Doctors Company

The Florida Board of Dentistry (BOD) takes a dim view of those who alter dental records. If a licensee is found to have altered a dental record, the BOD has a full range of penalties available to address the violation, including loss of the dental license and significant monetary penalties.

The Florida Department of Health (DOH) is the agency charged with investigating and prosecuting violations of the Dental Practice Act, including the issue of whether dental records have been altered in violation of the requirements of the BOD. The DOH has a wide range of statutory violations to choose from when presented with altered dental records.

Under the BOD’s Rule 64B5-13.005(3), if the DOH believes the alteration of the dental record was intentional and constituted fraud or making a false or fraudulent representation, it will seek a minimum mandatory fine not to exceed $10,000 for each count or separate offense, in addition to any other penalties outlined in the Board’s disciplinary guidelines.

Typical charges for altering the dental record include the following possible violations and subsequent penalties:

TDC table

Most professional licensing boards view altered records as evidence of a fundamental character flaw in the licensee and they will seek the higher range of penalties including suspension and loss of the license. The BOD is no different.  

Although permittable, if you need to make a late entry in the dental record, to avoid any allegation that you are seeking to alter the dental record, you should follow the BOD’s rule on record keeping. Rule 64B5-17.002(2) states: “Record Alterations: Any additions, corrections, modifications, annotations or alterations (hereinafter ‘change’) to the original dental record entry must be clearly noted as such and must include the date when the change was made, must be initialed by the person making the change, and must have an explanation for the change. An original entry to the record cannot be partially or wholly removed. Rather, to represent the deletion of a record entry, the entry must be struck through where it will remain legible. A change made on the same date of the original entry must also include the time of change.”

This requirement is applicable to handwritten records and electronic records. If you have any doubts before you make alterations or changes to a dental record, consult with an attorney.

 

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

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.

 

 

Disaster Preparedness for Your Dental Practice

By Julie Brightwell, JD, RN, Director, Healthcare System Patient Safety, The Doctors Company

Recently, hurricanes, floods and fires nationwide have highlighted the importance of planning for disasters. Hurricane and flood damage in Texas and Florida left practices without power for days or even weeks. Wildfires in California forced several dentists to quickly relocate their practices ― some permanently ― and to move scheduled procedures to different facilities. Is your practice prepared for this type of situation?

A disaster can overwhelm a dental practice, with damage that can include shattered windows, flood debris, power outages, disrupted telephone systems, computer and system outages, unsafe drinking water, destroyed dental records, medication exposure to temperature and humidity extremes, contaminated instruments and building structure failure.

Disaster preparedness requires a continuous cycle of planning, organizing, training, equipping, rehearsing and evaluating. Dentists are critical participants in disaster preparedness, ensuring that patient care and critical services are not interrupted.

Plan Ahead Now
Before the next disaster strikes, make sure your practice has a plan in place. A checklist, ordered by priority and customized to specific types of disasters, can provide the framework for a comprehensive plan. The checklist should include these elements:

  • A full-circle call tree that outlines who contacts whom.
  • Instructions for setting up instant messaging technology that enables staff to communicate without a wireless network or cellular data connection.
  • A Certificate of Insurance for your dental malpractice coverage, or instructions for contacting your agent or insurer directly to obtain proof of coverage. This document will be necessary if you are forced to temporarily relocate your practice or procedures.
  • Steps to follow upon returning from evacuation.

When Disaster Strikes
Planning today makes accomplishing the following tasks more feasible during a disaster:

Communication

  • Contact staff immediately to determine realistic time frames to return to work.
  • Notify external vendors and business associates of your practice interruption and targeted resumption of operation.
  • Implement staff briefings at the beginning and end of each day.
  • Create temporary phone, fax and answering services.
  • Establish patient telephone triage.
  • Implement temporary controls to ensure HIPAA compliance.

Computers and systems

  • Contact computer service vendors to ensure integrity and recovery.
  • Verify insurance coverage for repair or replacement costs and losses.
  • Evaluate applicable warranties and consider an information technology restoration service contract.
  • Inventory and document hardware and software.
  • Document the type and extent of both lost electronic and paper data.
  • Ensure data backup and periodically test compliance.
  • Re-establish filing systems and internal programs.

Dental records

  • Determine the extent of damage to, or loss of, patient records and filing systems.
  • Attempt to restore all damaged charts and document inventory findings.
  • Notify the state dental board for specific guidance pertaining to lost or damaged records.
  • Document all efforts to restore and protect existing records.
  • Reconstruct lost charts at the next patient encounter.
  • Contact your insurance carrier for restorative services and/or claim procedures.
  • Re-establish a filing system and temporary storage if necessary.
  • Obtain legal guidance for patient notification during recovery efforts.
  • Contemporaneously date and initial all late entries and duplicate information in context of recovery efforts.

In addition, create an inventory of all equipment and medications that may have been exposed to water or extremes in temperature. Repair, replace or discard damaged items appropriately.

Once your plan is in place, regularly re-evaluate its steps and update all contact information. Practice and rehearse the plan’s protocols. An effective disaster preparedness plan will help keep your practice focused on delivering care during an emergency.

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.

Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

Is Your Patient a Victim of Human Trafficking?

By Amy Wasdin, RN, CPHRM, Patient Safety Risk Manager II, The Doctors Company

Most health care providers are aware of their role and responsibility to identify and report victims of child abuse, elder neglect and domestic violence. However, there is another type of abuse that is on the rise and reported in every state throughout the nation. In 2016, human trafficking cases reported in the United States rose by more than 36 percent from 2015, according to the National Human Trafficking Hotline statistics.

Human trafficking occurs when a trafficker exploits another individual with force, fraud or coercion to make him or her perform labor or sexual acts. Victims can be any age (adults or minors), any gender, and from any cultural or ethnic group. The trafficker, or abuser, might be a stranger, family member or friend. This criminal industry is extremely profitable, generating billions of dollars worldwide. Lack of awareness and misconceptions by health care providers allow opportunities for identification of the victims to go unnoticed and unreported.

Victims of abuse rarely find opportunities to interact with other persons without approval from the abuser. A visit to a physician or dental practice may provide a rare opportunity for a patient to receive the help that he or she desperately needs. Research published in the Annals of Health Law in 2014 revealed that 87.8 percent of trafficking survivors reported that they were seen by a health care provider during their trafficking situation.

Human trafficking victims commonly are seen in medical and dental practices with the following conditions:

  • trauma such as broken bones, bruises, scars, burn marks or missing teeth
  • poor dental hygiene
  • pregnancy
  • gynecological trauma or multiple sexually transmitted infections (STIs)
  • anxiety, depression or insomnia

Victims usually are afraid to seek help for a variety of reasons that usually stem from fear, shame or language barriers. Health care providers and their staff should be trained to recognize the signs of human trafficking and know what steps to take.

Red flags to look for from the victim include:

  • fearful demeanor
  • depressed or flat affect
  • submissive to his or her partner or relative
  • poor physical health
  • suspicious tattoos or branding
  • lack of control with personal identification or finances
  • not allowed to speak for himself/herself
  • reluctant or unable to verify address or contact information
  • inconsistency with any information provided (medical, social, family, etc.)

Victims may be fearful and untrusting of their environment, so it is best not to directly ask an individual if they are a victim of human trafficking. Instead, the Department of Health and Human Services recommend questions such as the following:

  • Has anyone threatened you or your family?
  • Can you leave your job or home if you want to?
  • Are there locks on your doors and windows to keep you from leaving?
  • Do you have to get permission to eat, sleep or use the restroom?
  • Has someone taken your personal documents or identification?

Human trafficking is a federal crime and violators who are prosecuted receive prison sentences. The Trafficking Victims Protection Act was enacted in 2000 and provides tools to address human trafficking on a national and worldwide level. Many states also have laws and penalties for human trafficking.

If you suspect that a patient is a victim of human trafficking, please call the National Human Trafficking Hotline at 888.373.7888 or go to https://humantraffickinghotline.org/report-trafficking to report online. The hotline is not a law enforcement or investigative agency, but will take any possible steps to aid the victim and could result in a report to law enforcement.

Health care providers should follow state laws regarding mandatory reporting to provide notification of patient abuse or neglect situations. Unless calling the authorities is mandatory, it is recommended that you do not do so without the patient’s permission.

For resources and information on assessment tools, go to the National Human Trafficking Hotline’s Resources for Service Providers or Centers for Disease Control and Prevention.

 

Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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.