Dr D was a recent graduate who worked in a multidisciplinary clinic, where he had access to helpful advice from experienced clinicians. He examined Mrs H, an elderly lady, as an emergency patient. She reported intractable dull pain from an upper premolar, which had broken around a month prior. Dr D obtained a detailed medical history and confirmed that Mrs H’s chronic medical conditions were well managed by her medication and stable.
Upon examination, Dr D determined that the premolar had extensive caries, was unrestorable, and required extraction. He shared these findings with Mrs H and documented his discussion in detail in the clinical notes. Mrs H mentioned to him that she had been told by other health practitioners that she could not have local anaesthetic containing adrenaline, having previously experienced palpitations. Dr D acknowledged this and noted it contemporaneously in the clinical record. He obtained written consent for the extraction and then proceeded to administer the local anaesthetic, which had been assembled by his dental assistant, who had been in the room throughout. Dr D did not check the contents of the syringe at that time.
Dr D delivered the carious premolar uneventfully, achieved haemostasis, sat the patient up and then proceeded to manage the sharps by dismantling the syringe and placing the needle and the carpule in the sharps container. While doing so, he noticed that his dental assistant had loaded the syringe with an anaesthetic carpule containing lignocaine and adrenaline. Dr D immediately informed Mrs H off his error, apologised profusely, and asked how she was feeling. Mrs H indicated she had somewhat shaky legs but, more importantly, she was very upset that she was administered adrenaline against her specific wishes.
Dr D called in a more experienced clinician who reassured Mrs H that she would be fine, and he subsequently arranged a follow-up call with her and ascertained that apart from a headache, this was indeed the case. Prior to her discharge, Mrs H advised Dr D’s colleague that she felt he had performed a very good extraction, but that he should be reprimanded for his error.
About one week later, Dr D received an email from the state-based health regulator, advising him of a notification from Mrs H about his care and their decision to refer the complaint to AHPRA for investigation. The AHPRA letter was received a fortnight later, seeking a written response to the complaint. Dr D was naturally upset to know of Mrs H’s actions.
Management of the notification
Dr D contacted Dental Protection to seek advice on how best to respond as soon as he received the first regulatory notification. We recommended he forward the notification and his records for assessment. Dr D’s records were clearly comprehensive and helpful in establishing that his pre-operative assessment of Mrs H, history-taking, consent process and overall care were all of a very high standard, apart from the error in the anaesthetic administration. We advised him that Mrs H did not experience any significant or ongoing harm and that his treatment of her was otherwise of a very high standard, and assisted him in the preparation of his written response.
Importantly, Dr D did not at any time try to project blame for administering adrenaline onto his dental assistant. He acknowledged in his response to AHPRA that he understood his professional responsibilities, specifically around being accountable for knowing the type, dose and appropriateness of any medication prescribed or administered to a patient. A supporting letter from his senior colleague, corroborating Dr D’s version of events and his management of Mrs H, was included in his submission to AHPRA.
A further three weeks later, Dr D received an email from AHPRA advising that in their view, he had appropriately disclosed the error in anaesthetic administration to Mrs H and escalated her management, noting that the error was highly unlikely to have had any adverse effects. They advised that no further action would be taken.
Outcome
Dr D’s clinical records were of a very high standard and comprehensively documented his care of Mrs H, including his disclosure of his error. This was consistent with open disclosure obligations and helped demonstrate his ethics in owning the outcome of his actions. He followed up Mrs H appropriately and realised that he must always check the contents of any syringe or medicine being used on any patient. Dr D’s professionalism, remorse and commitment to future safe practice helped him avoid any adverse regulatory action.
Learning points
- Always thoroughly document any specific wishes of patients as part of the documentation of your consent process.
- Check the type and contents of any medicament, anaesthetic or drug used on a patient, and compare it to the medical history. If in doubt, delay treatment until it can be ascertained that it is safe for the substance to be administered, or substitute an alternative substance if clinically appropriate to do so.
- Should an adverse outcome arise in the care of a patient, document the outcome thoroughly, including all actions taken by you to manage the situation. Seek advice if unsure.
- Disclose any adverse outcome to a patient. It is better that the patient hears it from you, than from another clinician who may be judgemental of the situation, in the absence of knowing the context of how it has occurred.
- In most jurisdictions it is appropriate to apologise to a patient for any clinical error, as this can go a long way to avoiding further action (although not always, such as in this case) and is not normally regarded as an admission of liability.
- Irrespective of whether anyone is harmed in the provision of dental care, patients (or any other party) may choose to make a notification to state-based regulators or AHPRA. Contact Dental Protection to seek advice on how best to respond.