“man cannot control the current of events, he can only

5/8/2014

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Limiting Dental Risks/1

“Man cannot control the current of events, he can only

float with them and steer.”

Otto von Bismarck 1815 - 1898

Limiting Risks and Preventing Litigation

in Your Dental Practice FLORIDA NATIONAL DENTAL CONVENTION

Orlando, FL

June 12 – 14, 2014

Sandra Strickland, RN, MSN, LHRM, CPHRM

Director of Patient Safety – SE Region

Disclosure

We would like to disclose that Sandra

Strickland, as an employee of The Doctors

Company, has a financial interest in The

Doctors Company, an organization that may

have a direct interest in the subject matter of

this dental education presentation.


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Objectives

• Name the top dental practice risks

• Recognize communication barriers for

patients

• Identify strategies to decrease risks that

may lead to litigation


What is Malpractice?

• Duty Owed

• Breach of Duty

• Injury

• Causation

• How do patients measure standard of care?


Why patients sue?

• Unrealistic expectations

• Dissatisfaction with treatment

• Lack of communication

• Provider attitude

• Feel they’ve been wronged

• Anger

• Revenge or retaliation

• Entitlement attitude


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Top Dental Misadventures

1. Improper performance

2. No dental intervention when needed

3. Failure or delay in referral

4. Failure to supervise or monitor care

5. Wrong tooth

6. Foreign body retention

7. Errors in diagnosis

Source: PIAA Report July 2009


Top Dental Procedures

• Extractions

Surgical and forceps

• Root canal

• Implant

• Dental restorations

• Local anesthesia


Failures

• Consent

• Referral

• Complications

• Perform prosthodontics, endodontics

and orthodontics

• Diagnose and manage – infection,

perio disease, tumors


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Failures (continue)

• Render appropriate endodontic care

• Manage implants

• Extraction

• TMJ

• Supervise staff

• Slips, falls, burns, cuts

• Anesthesia incident


Controllable Risks in a Dental Office

• Documentation problems

Non-compliance

Follow-up

Consent discussion

• Communication failures

Low health literacy

Listening

Consent

Complaints

• HIPAA

• Medication


How can I be prepared?

The bringing of a lawsuit by a

patient is out of our control.

Our defense

–found in our documentation–

is within our control!


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Malpractice Lawsuits

What do plaintiff attorneys look for?

Missing records

Incomplete records

Gaps in time

Finger-pointing

Sparse documentation

Altered records


Documentation Problems

• Subjective comments

• Abbreviations

• Alteration and corrections

• Absent or incomplete/Gaps

• Failing to read chart

• Evaluation – Patient status


Documentation Problems (continued)

• Treatment rationale

• Consent discussion

• Assigning blame

• Inconsistencies

• Release and retention


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Recent Case

Extraction of tooth #19 Informed consent signed with RDA

Patient has no questions, extraction proceeds normally

Patient calls later c/o facial numbness

Numbness has now lasted two months

Dentist reviews his documentation No pre-op discussion of numbness noted

Section on consent form discussing numbness not initialed

Will patient bring a lawsuit?


What do I document?

Assessment/Evaluation

Treatment options

Informed Consent with date and time

Care provided

Procedures performed

Communications with patients

Education of patients and family

Patient participation

Patient status

Fees


FAC 64b5-17.002

Follow Up on Non-Compliance

• Tracking system

• Follow up - reschedule

• Document Efforts and patient response

• Letter to address

• Explain importance

• Consider withdrawing, if necessary


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Documentation Practices

• Patient discussions and instructions

• Communication with providers

• Use of educational aides

• Use of an interpreter

• Informed consent process

• Phone calls

• Referrals


Best Practice Documentation

• Objective

• Standard abbreviations

• Non-erasable ink

• Legible

• Date and time all entries

• Date and time informed consents

• Do not fail to date and time late entries


Examples—Subjective or Objective?

Case #1 “Patient probably hasn’t touched a toothbrush in ten years.”

or “Exam reveals poor oral hygiene including multiple caries

and gingival disease.”

Case #2 “Patient called asking for more drugs. Definite drug seeking.”

or “Patient called in requesting refill of Vicodin after using full

prescription of #30 in three days. Patient was advised that if pain was that severe, he/she should come in to be seen.”


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Communication Barriers

• Physical stressors

• Emotional stressors

• Literacy

• Language

• Overload

• 80 percent - Information from doctor is forgotten

• 50 percent - Recalled is incorrect


A New Vital Sign: Health Literacy

• Risk of misunderstanding dental treatment

• Risk of problems with prescriptions

• Lower health status

• Poorer dental and health outcomes

Compliance issues


Informed Consent Communication

• The Discussion

Nature of the procedure

Risks, complications, expected benefits,

or effects of the procedure

Alternatives - their risks and benefits

Potential conflict of interest

• Research

• Financial

• Easy to understand terms


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Handling Complaints

• Alert dentist

• Strict confidentiality

• Listening skills

• Trigger to improve

• Trends and action plans

• Training

• Follow-up


The Complaining, Demanding Patient

Wants:

To be taken seriously

To be treated with respect

To be listened to and heard

To have the problem acknowledged

Someone to take immediate action

To be assured problem will not recur


Communication Strategies

• Safe environment

• Plain language

• Eye contact

• Visual models

• Listen

• Solicit questions

• Teach back

• Written instructions

• Outcomes


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HIPAA Violations

• Failure to follow federal/state requirements

• Failure to train staff

• Unauthorized release of PHI (protected health information)

• Breach of PHI Lost or stolen PHI: laptops, drives


In the News: HIPAA Violations

• Cignet Health Ignored 41 individuals’ request for access

to their records

$4.3 million civil monetary penalty assessment

• Massachusetts General Hospital Employee left 192 patient files, including patients

with HIV/AIDS, on the subway train

OCR received settlement that included payment of $1 million

HHS News Release February 2011


Patient Rights

• Notice of privacy practices

• Privacy protection Written information

Personal privacy

• Confidential communication

• Access to information


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Disclosure of PHI

• Disclosure permitted without patient’s consent: Treatment

Payment

Operations

• Consent also not required for:

Abuse

Coroner

Public health


What Can Get You in Trouble

• Mistakes

• Faxing and copying

• Centralized release of EMR

• Mistaken identity

• E-mailing

• Texting

• Social networks


Penalties for HIPAA Violations

• Knowing violation Fine $50,000 and/or one year in prison

• Offense under false pretenses Fine $100,000 and five year prison term

• Offense with intent to sell, financially benefit, or maliciously use medical information Fine of $250,000 and up to

10 years in prison


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Privacy Laws and Your Role

• Training - staff and providers

• New hires and updates

• Document

• “Need to know” and “minimum necessary” limitations

• Mindful of public places

• Out of sight

• Out of earshot

• Encryption and password protections

• PHI disposal

• Confirm numbers and addresses

• Never leave documents unattended


Medication Safety

• Security

• Document administration and prescriptions

• Update medications list

• Medication reconciliation prior to:

Prescribing or administering

Procedures

• Avoid verbal or telephone orders

• Monitor narcotic prescriptions

• Include indication and text + numeral in prescriptions

• Monitor patients receiving anesthetic


Be Prepared for Allergic Reactions

• Five percent of patients do not know they have a drug allergy

• Check allergies every visit

• Allergic reaction - most common emergency

• Be prepared to recognize and respond to allergic reaction

• Practice drill at least twice a year


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Thou Shalt Never

1. Do a procedure without explaining it to

the patient

2. Start a procedure without ensuring the

patient understands what you plan to

do and consents to the procedure

3. Fail to obtain an informed consent

when necessary

4. Argue with patients


Thou Shalt Never (continued)

5. Amend documentation without making note of the date and time of the change

6. Forget to document

7. Ignore legal correspondence

8. Forget to call your PL Carrier when you receive legal correspondence


Decrease your Liability

• Evaluate and improve your practice

• Focus on customer satisfaction

• Manage patient expectations

• Document

Communications

Informed consent

Patient response

Follow up with non-compliance

• First line of defense – office staff

• Contact your PL Carrier for support services


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Click to edit Master title style

• Click to edit Master text styles

Second level

• Third level

– Fourth level

» Fifth level

40

“The pessimist complains about the wind; the optimist expects it to change;

the realist adjusts the sails.”

--William Arthur Ward

Limiting Dental Risks/

For additional Patient Safety information

please visit our Web site at:

www.thedoctors.com

Our Mission is to advance,

protect, and reward the

practice of good medicine.

[email protected] (800) 421-2368 ext. 3263


“man cannot control the current of events, he can only

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