Avoiding the banana skin

28 January, 2011 / Infocus

Accidents will happen. Show me a dentist who has never made a mistake and I will show you a dentist who has never practised dentistry. And in truth nobody expects dentists to be perfect – not the General Dental Council (GDC), not their fellow dentists, not the man or woman in the street, not even the no-cure, no-pay lawyer…

After all, dentistry is not a straightforward business. It’s not like washing a car or peeling a potato. You’re dealing with living tissue inside the mouth of a living, breathing human being. There’s plenty to go wrong – and more besides. When you consider that it is easier for patients to make a complaint to the GDC than ever before (there was a time when they had to contact a lawyer and swear an affidavit; now they can just pick up the phone) and there are more and more lawyers actively scouting for malpractice suits, it’s no surprise many dentists spend their lives thinking they’re going to be sued.

But the reality is that we as a profession are hardly ever sued. The reason is simple. When it comes to errors in the dental clinic, it’s not the procedure gone wrong that generally gets dentists called up in front of the GDC, but rather the subsequent attempt to cover it up. Take out the wrong tooth, drill on the wrong side of the mouth to the local anaesthetic, and evidence from both the UK and the US shows that, in cases where dentists hold their hands up and admit the error, less than two per cent of patients will want to take the matter further.

Try to cover it up, on the other hand, by pretending it’s not your fault, blaming your nurse or the laboratory, or simply denying there’s a problem, and patients already unhappy about an unsatisfactory experience will begin to feel angry and frustrated and – research shows – are much more likely to raise a legal action or complain to the GDC, with potentially devastating consequences.

In one famous case in the last decade, after making a mistake with a patient’s dentures and subsequently refusing to acknowledge it, a dentist found himself at the end of the disciplinary line and struck off altogether. He was reported to the NHS Ombudsman, who found independent evidence that the dentist had made a mistake and been rude to a patient. He was ordered to apologise but refused.

It so happened that there was another case involving treatment that this dentist had refused to put right, and when he declined to apologise to this patient as well, the Ombudsman reported him to the GDC. There followed a further investigation into the treatment and he was called before the council. I remember his conduct case well. In addition to refusing to accept he’d done anything wrong , in an excessive display of arrogance, he was utterly dismissive of one of the patients.

The outcome of the enquiry and the conduct case – that began, I remind you, as one complaint about dentures and one about fillings – was that the dentist persuaded the panel he simply wasn’t a fit person to practise dentistry. He ended up being struck off because he in effect provoked an investigation into, not so much the quality of his work, but his professionalism and his attitude.

What’s more, despite being struck off, he continued to practise dentistry. The result was to be featured in a TV programme about ‘nightmare dentists’ as well as face a criminal prosecution brought against him by the GDC. All of which means that his chances of ever being restored to the register are very slim indeed. And all this arose from a simple failure to say: “I’m sorry, I got it wrong. Let me put it right.”

This case is at the very extreme end of the spectrum and almost all cases are of a different, smaller order of magnitude. But nevertheless the mistake waiting to happen is one of the realities of life as a dentist, and it should be clear that honesty and an apology are always the best policy. Should you ever be in doubt about what to do, whether or not a formal complaint has been made, always contact your defence organisation without delay.

Of course, it is profess- ionally advantageous to keep the number of apologies you have to make to a minimum, and there is a lot that dentists can do to alter the probabilities in their own favour, simply by recognising the situations and factors that lead to mistakes, and acting to minimise the likelihood of them happening in the first place.

Life doesn’t go on hold when you step into the surgery, and multiple distractions are a common cause of error. Just because you’ve seated your patient and administered a local doesn’t mean the phone isn’t going to ring with bad news, whether it’s your bank manager calling up to tell you your overdraft’s been exceeded or your life partner informing you about burst pipes at home. And just because the news wasn’t good doesn’t mean your receptionist isn’t going to announce, when you’ve put the phone down, that she’s going home early with a headache.

Distractions like this can throw you off kilter, puncture your concentration, and require a conscious effort on your part to tune back in to the patient and the procedure at hand – simply being aware of the possibilities can reduce the risks of error.

Like multiple distractions, the over-full appointment book is to be avoided – or, if not, at least recognised as a potential source of problems. It only takes one extra emergency case, for example, to put you behind and pile on the pressure. If you’re mindful of this, you may well decide to get back on track by doing less than you’d originally planned for one or two patients in that day’s book, or perhaps even ask a non-urgent patient if they’d mind making a new appointment.

A study of GPs showed that the most stressful time, when things were most likely to go wrong, was just before lunchtime – in particular, if they were meeting their life partner for lunch and were already running behind. The study showed that, in these conditions, the GPs’ consultation times plummeted. Combine a short consultation with a highly technical procedure and the chances of things going wrong soon begin to escalate.

Of course, dentists don’t work in a vacuum but are surrounded by staff who watch their every move. Here, too, is an opportunity to minimise error that is not to be missed. Fostering a supportive relationship with your nurse, for example, and making it clear that you’re open to being corrected and challenged, will go a long way to cutting mistakes.

Put your nurse down angrily the first time she suggests you’re anaesthetising the wrong tooth – whether she’s right or wrong – and she may well not speak up when she spots you preparing to extract an upper left four instead of a lower left one…

Plain speaking and honesty are to be encouraged, too, when reflecting on your own practice, as this is a crucial means of ensuring you don’t fall prey to that other common cause of mistakes: becoming deskilled. This can happen for a number of reasons, such as a career break to bring up a family, a period of illness, or perhaps because a colleague in the practice who always did a particular type of clinical procedure for you has moved on or retired, leaving you to take on procedures you may not have tackled for years.

In my own case, back problems put me out of action for the best part of a year, and when I went back to work, I found, every now and again, I’d missed a stage out such as forgetting to take an impression for the mould for the temporary before I completed the prep. It’s very easy if you haven’t done something for a long time to forget exactly how to do it.

Recognising you have a problem is just the first step. Now you have to do something about it. Well, textbooks are tax-deductible and the internet is always on, so that part is easy. But I also recommend going along to your postgraduate tutor, your old den
tal school or your defence organisation, and quietly locating a little help to get yourself back on track in the procedure in question. You are rarely going to require across-the-board help; the fundamentals will still be there, but you may just need a little help with your technique to boost your confidence.

Failing that, dentists in this predicament tend to struggle and compromise, avoiding certain treatments (which can later become an issue of neglect) or simply doing them badly. Even those dentists who do undergo some ongoing training, if they are not being straight with themselves, might choose to avoid a hands-on course where they are being watched and opt instead for an online tutorial. Alternatively, they may book themselves on to a course on their favourite topic, instead of one where they actually have a need to improve.

What dentists must not do is to go home at night unhappy and depressed because they feel their skills are not up to the job. In the majority of cases where there has been some kind of deskilling, it’s almost always just a question of some fine-tuning, a bit of confidence-boosting and some help with one or two technical issues.

Just as important as keeping your skills up to date is keeping your records up to date. Poor record-keeping can lead to misunderstandings, such as putting a local anaesthetic into a tooth you’ve already taken a nerve out of, or preparing the wrong molar. What’s more, unsatisfactory records are often exposed after a complaint is made to the GDC, so that although the topic of the complaint may not amount to much, the subsequent enquiry picks up a failure to do things properly, and matters can escalate.

The records must be good enough to stand up to scrutiny from external reviewers, and that means X-rays of good quality, properly labelled, and precise – and concise – notes in clear handwriting or, as is more usual now, typed. ‘Essays’, very often lacking the crucial information, are not helpful. I’ve seen extremely long entries that fail to mention which tooth was involved in the procedure. Quality of information, not length, is the key here.

And finally, it’s worth remembering that poor record-keeping is a double-edged sword: it doesn’t just lead to errors that can get you into trouble, but once you’re in the spotlight, it makes it a lot more difficult for your defence organisation to help you. If a patient complains, after 10 or 20 years, that you never told them they had gum disease, or, if you did, that you didn’t do anything about it, good records and decent X-rays will go almost all the way to proving the contrary. A little time and effort spent now can save you a lot of pain in years to come.

Hew Mathewson is a general practitioner in Edinburgh, a special adviser to the MDDUS and a former President of the General Dental Council.

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