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, 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 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.
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.
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 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
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. 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
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.
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 informed consent for their treatment. Specific informed consent for surgery, endodontics, periodontics, complex prosthodontics, and sedation techniques was also lacking. The 2005 ADA malpractice survey results indicate that inadequate record keeping is one of the primary violations committed by dental healthcare providers, and these inadequacies may result in board remediation or malpractice charges (ADA, 2007). Dentists who have presented liability claims often have not sufficiently documented their patients’ treatment plans, medical history, or informed consent/refusal. If dental healthcare providers understand these record keeping errors and correct them, they might avoid the resultant charges alleging malpractice. All pertinent information from the survey is available at http://www.raedentalmanagement.com/wp- content/uploads/2014/03/ADA-Dental-Records.pdf. The ADA Council of Dental Practice/Division of Legal Affairs recommends that all dentists assess their record keeping practices in light of the issues identified in the survey and address problematic practices as needed. Proper charting methods According to the ADA Council on Dental Practice, the dental record (patient’s chart) is the official office document that records all of the completed and proposed treatment and all patient-related communications that occur in the dental office (ADA, 2007). State and federal laws or regulations determine how the dental record is handled, how long it is kept, and who may have access to the information. The dental record
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