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A near miss – on the last day of practice

30 October 2020

A Dental Protection member, who is a registered specialist, shares this experience from their last day in dentistry


You will be pleased to learn that I did not operate on the wrong patient on my very last day of local anaesthetic cases. But let me tell you what happened.

In all of my years I have never operated on the wrong patient, although I did once take out the wrong tooth. I ‘owned’ the problem, providing free treatment for that 13-year-old until she was old enough to have orthodontic treatment (pro bono), followed by my insertion of an implant (again pro bono), which was then followed by successful prosthetic restoration (again pro bono). There was never a lawsuit.

Last Saturday I had my final list of local anaesthetic cases. The protocol I have adopted is to welcome the patient to the room, introduce my staff, ask them to place protective spectacles in position, and explain that I will be putting a cotton bud with topical local anaesthetic in the area before proceeding with a local anaesthetic. I go through a standard patient identification process. My notes said that this patient was called – let's say ‘Bill Smith’ – and when I asked him if he was Bill Smith he said “yes”, and when I asked him if his birthday was –  let's say 9/9/1999 – he said “yes”.

The OPG x-ray and the clinical notes treatment plan indicated that I was to take out an isolated tooth #27, but when I looked in the patient's mouth the #27 was abutting against a perfectly healthy #26, and it was also evident that his lower wisdom teeth were impacted. I then asked my patient again if his name was Bill Smith. He replied: “No, I am Sam Jones.”

I then swapped charts and put Sam’s x-rays up on the view box and did the correct operation on the correct patient. That is the third time in 35 years where I have had a patient misidentify themselves! I guess it’s called the ‘White Coat Syndrome’.

The dentolegal perspective

By Dr Mike Rutherford, Senior Dentolegal Consultant, Dental Protection

This story is not unique. Fortunately the practitioner’s attention to detail and a distinctive and unexpected dental appearance triggered alarm bells, averting what could have been a terrible outcome for ‘Sam Jones’ and a very unfortunate conclusion to a long and illustrious career for this practitioner.

Even if treatment is not carried out, but merely initiated before the confusion is recognised, our patients can be fearful of the imagined disaster they have just avoided.

We need a ‘time out’ protocol, as this colleague had – right patient, right procedure and right site; but even then, we must be alert to the possibility that this is not foolproof. Most dental practitioners would have experienced something similar to this story – calling a patient’s name in the waiting room and having someone else stand up and follow you down the corridor. Generally this is sorted out when formal identification of the patient is made in the surgery, but why does this happen in the first place? Some patients may be hard of hearing, some recognising a familiar practitioner at their expected appointment time automatically stand up without processing the name. The majority though are likely, as our colleague suggests, to experience ‘White Coat Syndrome’ – a patient, anxious and thoughtful about their toothache or the treatment they are about to receive, blocks out extraneous thought processes and follows unwittingly.

It is up to us as dental professionals to ensure all is as it appears to be, and use more than just patient collaboration to confirm the ‘time out’ protocol. This can extend further to such processes as medical histories, when a preoccupied patient may miss disclosing some information or not recognise the intent of a question – always verify and ask for patient elaboration on information given, or even not given, if there is an unexpected answer. Yes, it is a patient’s responsibility to provide us with correct information, but it is also sound professional practice to be alert for possible inconsistencies – and a lot less stressful on our practising lives.

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