“man cannot control the current of events, he can only
TRANSCRIPT
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
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What is Malpractice?
• Duty Owed
• Breach of Duty
• Injury
• Causation
• How do patients measure standard of care?
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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
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Top Dental Procedures
• Extractions
Surgical and forceps
• Root canal
• Implant
• Dental restorations
• Local anesthesia
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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
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Controllable Risks in a Dental Office
• Documentation problems
Non-compliance
Follow-up
Consent discussion
• Communication failures
Low health literacy
Listening
Consent
Complaints
• HIPAA
• Medication
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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
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Documentation Problems
• Subjective comments
• Abbreviations
• Alteration and corrections
• Absent or incomplete/Gaps
• Failing to read chart
• Evaluation – Patient status
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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?
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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What Can Get You in Trouble
• Mistakes
• Faxing and copying
• Centralized release of EMR
• Mistaken identity
• E-mailing
• Texting
• Social networks
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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
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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
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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
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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
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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
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“The pessimist complains about the wind; the optimist expects it to change;
the realist adjusts the sails.”
--William Arthur Ward
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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
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