An adverse event is defined as an injury to a patient resulting from poor medical management by a healthcare provider or equipment malfunction that results in serious injury or death. Each year, an estimated 3% to 4% of all patients who receive health care are involved in an AE. More specifically, an AE in dentistry would be defined as an injury to a patient resulting from poor dental management provided by a dental healthcare provider or from an equipment malfunction that results in patient injury or death. An AE that is caused by operator error and was preventable is called a sentinel event. Preexisting medical or dental conditions do not lead to AEs. Charges of malpractice are usually the result of adverse events. Malpractice is any improper treatment or lack of treatment by a medical or dental healthcare provider that violates generally accepted medical/dental standards of care. In a 2004 article, “The Standard of Care in Dentistry,” in The Journal of the American Dental Association, Joseph P. Graskemper, DDS, JD, relied on the 1970 decision of the Kentucky Court of Appeals in Blair v. Eblen to define the standard of care in dentistry: “[A dentist is] under a duty to use that degree of care and skill which is expected of a reasonably competent [dentist] acting in the same or similar circumstances” (see Blair v. Eblen , 461 S.W. 2d 370, 373, KY, 1970; Justia, n.d.). In successful malpractice claims, the medical/dental healthcare provider’s provision of care is determined to have departed from the standard of practice and resulted in harm to the patient. In order to address the issue of patient safety, dental healthcare providers must comprehend the complexity of these problems, the scope of medical/dental errors and how to develop an action plan to prevent further errors, the laws and regulations by which they are governed by their profession and state, and the potential consequences of their actions (AHRQ, This section discusses the most common types of medical/ dental errors, along with some error-reducing strategies to prevent their occurrence. Many of the error-reducing strategies System-based errors Most health care is delivered in a rapidly moving, hectic environment – through a set of complex systemic processes – which provides a climate for error. Several factors may lead to system failures, such as poor system design and inadequate organizational strategies. These system flaws contribute to such specific types of errors as medication errors, surgical errors, and diagnostic errors. Several measures have been developed in recent years to address system-based issues. Many healthcare organizations have adopted the use of “red rules” as an error-reduction strategy. Red rules were used originally in the nuclear power industry. They are rules that cannot be broken. They are steps that should be undertaken every time a particular process is carried out, except in rare and urgent cases (Morath, 2008). Examples of red rules in dental care might be “no biopsy or other consultation reports placed into the patient’s chart unless the dentist reviews, dates, and signs the report” or “the use of a rubber dam for every endodontic procedure.” Red rules should not be overused and should be reevaluated regularly. Healthcare organizations report that they have been highly successful in using red rules to reduce system-based errors (Morath, 2008; Scharf, 2007). Policies such as these reflect the organization’s perspectives on patient safety and the organization’s accountability for the welfare of patients and employees.
be familiar with the ADA Code of Ethics, federal legislation, and his or her respective state regulations for dental practice. There is an abundance of information about the type and frequency of AEs in medicine and an ever-increasing recognition of AEs in dentistry. The main source of information about AEs comes from the review of dental records. This is usually a random review and its dependence on the record keeping techniques of dental healthcare providers may limit its accuracy. Kalenderian, Walji, Tavares, and Ramoni (2013) created a dental clinic trigger tool based on the Institute for Healthcare Improvement (IHI) global and outpatient trigger tools. The tool that Kalenderian and colleagues developed identifies records with characteristics or “triggers” that are involved with AEs. Procedures for incision and drainage, failed implants, and selected treatment patterns were among the triggers used. They used this trigger tool against six months of electronic health records data compared with the review of 50 randomly selected patient records in a dental school setting.
n.d.a). Most states have a dental practice act or laws and regulations that govern the practice of dentistry. For example, in Florida, dental healthcare providers must comply with the Florida Dental Practice Act, administered by the Florida Board of Dentistry. Additionally, every dental health provider should Using this method, 315 records were triggered, of which 158 (50%) were positive for one or more AEs; in comparison, 17 (34%) of the 50 randomly selected records were positive for at least one AE. Each AE received an IHI severity ranking. Nine of the AEs were considered to have caused permanent harm, while the remainders were considered minor or temporary. Because the dental clinic trigger tool was more effective in identifying AEs than a review of randomly selected records, the authors concluded that the results demonstrate the promise of a directed records review approach. They further concluded that all dental practices should proactively monitor the safety of the care they provide, and that the use of the trigger tool would help make this process more efficient and effective. This research supports the use of computers and electronic records to identify adverse events in dental practice. Electronic record keeping is also one of the most effective tools to defend against malpractice and board claims. However, prevention and safety are still key to avoiding medical/dental errors (Kalenderian et al., 2013). COMMON TYPES OF MEDICAL/DENTAL ERRORS AND ERROR-REDUCING STRATEGIES
can prevent or limit more than one type of error. These potential strategies range from simple standardized steps to the use of large information technology networks. Record keeping errors In order of frequency, the top record keeping errors identified in the 2005 ADA malpractice survey begin with the failure to document specific dental record components, such as a treatment plan, health history, informed consent, or informed refusal. Patients’ assessments were found to be incomplete; words, symbols, and abbreviations were ambiguous; and the records were not written in ink. Other record keeping errors included improperly documented telephone conversations and imprecisely or incompletely documented treatments. Subjective patient complaints and objective provider findings were incompletely documented. Treatment plans were often not supported by objective findings, and the reasons for changes in treatment were not properly documented or supported in the records. Missed and failed appointments were not documented, and records were often illegible. Patients received insufficient information concerning complex procedures and treatment, and documentation of the name and relationship to the patient of the person who provided informed consent for the procedure was missing. Failure to document patient referrals to, or consultations with, specialists was also identified as a major problem. Details of discussions with patients regarding referrals were not written in the progress notes, supporting patients’ charges that they were inadequately prepared to provide an
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