Iatrogenic injuries and what can be done to avoid them
29 July 2019
Wherever you are in the world, there is generally a legal obligation in place that sets out duties of employers to ensure appropriate standards of quality and safety in a dental practice. Simrit Ryatt, dentolegal consultant, looks into some iatrogenic injuries and what can be done to avoid them.
This legal obligation can include a delegable duty to team members to make sure equipment used in the treatment is safe and maintained to be in good working condition in accordance with manufacturers’ instructions. It is nevertheless important to emphasise that it remains the responsibility of the clinician who is handling a piece of equipment to ensure a patient is not inadvertently harmed, either by operator carelessness or equipment malfunction.
Experience is generally a good thing, as you become more comfortable with dealing with challenging situations throughout your working day. It is also worth bearing in mind that an experienced clinician may subconsciously become complacent about the risk attached to hazards in a dental surgery, particularly where the risk has been identified but not corrected for a while.
No matter how proficient you are, there are some scenarios that are impossible to predict and are not under your direct control, such as sudden movements or the behaviour of a patient. In light of this, it is important that we manage risk by focussing on the variables that we can control, by ensuring that a regular risk assessment of the surgery equipment and operative procedures is carried out.
A good example of how this may be put into practice is to plan procedures in advance and adopt a checklist approach to ensure that the required materials and equipment are readily available and on-hand.
It goes without saying that personal protective equipment at work should protect both the members of the dental team and patients. All members of the dental team play a part in identifying hazards and risks and reporting them before they cause injury. Risk assessment and reporting should be discussed at team meetings and followup actions should be notified to all team members. It is also important to keep a record of these discussions for future reference.
To help your understanding of how incidents can occur, we have highlighted some examples from our case library. We have also highlighted the learning opportunities each incident provided.
Case study – a laceration following an extraction
Mr D attended the dentist and during his examination he expressed his wish to have dental implants to restore the existing space he had from the extraction of teeth 45 and 46 around 20 years previously. The dentist also noted that tooth 47 had fractured beyond repair, but other than that, the patient had maintained a good standard of oral health.
How did the accident happen?
At a subsequent appointment, the dentist was using a luxator around tooth 47 that slipped and lacerated the adjacent soft tissue. The laceration on the inside of the cheek was severe and extensive.
How was this managed?
The dentist explained what had happened to the patient and offered an immediate apology. The area was sutured and a review appointment was arranged for the following day. The patient was contacted by telephone later in the evening and he explained he was in some discomfort and was aware of some swelling in the area of the wound.
At the review appointment
At the subsequent review appointment the wound was assessed and the swelling noted. As the injury had been caused by an error in technique, the risk of this type of injury had not been discussed.
The patient subsequently had to take a week off from work and advised the dentist of his intention to claim for compensation for his pain, suffering and loss of earnings.
The dentist called Dental Protection and our team was able to negotiate an early and appropriate settlement, protecting the member’s position and avoiding any risk of escalation.
Although the dentist was very experienced, the error was attributed to a lapse of concentration which had unfortunate consequences. On reflection, the dentist realised perhaps his access to the area could have been improved and his finger rests more stable and sturdy. His reflection and subsequent analysis was recorded and shared with the rest of the team in the expectation that a similar situation maybe prevented in the future.
Case study – a chemical burn
Miss C attended a surgery complaining of discomfort at tooth 27 following a dislodged restoration. A radiograph was taken, that showed that the distal-occlusal cavity was in close proximity to the dental pulp and that there was caries present. Miss C was made aware of the radiographic and clinical findings and informed that root canal treatment may be indicated.
As anticipated, during the process of excavating caries, the pulp was exposed and the first stage of endodontic treatment was carried out. During irrigation of the root canal system, the irrigation syringe tip detached from the body of the syringe and a small volume of sodium hypochlorite splashed over the patient’s face. Miss C was advised to immediately rinse her face, and the initial stage of the endodontic treatment was completed.
At the subsequent appointment Miss C reported some soreness in the area affected by the hypochlorite. The dentist completed the endodontic treatment and was satisfied with the postoperative result. The patient complained and requested compensation for the adverse incident and threatened to escalate her concerns.
After seeking advice from Dental Protection, it was agreed that the treatment fees should be waived and a contribution was made by Dental Protection towards the cost of treatment provided by a specialist dermatologist.
• Reflecting upon his treatment, and with the benefit of hindsight, the dentist acknowledged he should have used a rubber dam. The dentist always found accessing the tooth easier without a rubber dam and would generally place it after gaining access. He did not routinely apply a rubber dam at emergency appointments, and the incident reminded him of the need to do so in future.
• Always ensure that the irrigation needle is fully engaged on the body of the syringe and avoid excessive force during the irrigation process.
Case study – a burn injury to the lip and cheek during an extraction
During a surgical procedure under sedation, a dentist caused an accidental injury to the lip and cheek of Ms W. The surgical procedure involved making gingival incisions, raising a flap and trimming away bone to remove a partially erupted 48. During the procedure,the right cheek mucosa was burnt by contact with an electro-surgery tip that was being used to trim some soft tissue.
How was the situation managed?
The wound was carefully cleansed and closed with sutures.
The patient's fiancé joined her in the recovery room, and although they accepted the explanation at the time, they called later that evening to complain.
A month later the wound had healed fairly well, but there was a residual indentation remaining which was quite apparent. Ms W was concerned the indentation would be present in four months’ time, when she was due to get married. The dentist and his clinic agreed to arrange treatment for her with a plastic surgeon and they were informed there was a good chance the wound would heal completely with minor surgery.
Ms W went on to claim for compensation. Although the dentist had expressed his regret at what had happened and arranged for further specialist care, there was still an expectation that the exercise of a reasonable standard of care would have meant that such an injury would not have occurred.
A team meeting was held following the incident and everyone acknowledged how potentially easy it was to cause such an injury, especially when patients have been locally anaesthetised and also sedated. In recognising the risk, the team were in a position to avoid future occurrences.
Case study – crush injury
Mr K was booked in for a routine extraction of tooth 27, which had been causing discomfort and was unrestorable. A mesial-occlusal restoration was planned for 36 at the same appointment.
The dentist completed a composite filling in 36 and then set about extracting the 27.The procedure took longer than expected,but eventually the tooth was extracted in one piece.
Following the extraction, the dentist noticed Mr K had developed some bruising around the lower lip which had been caused by the forceps or elevator trapping the soft tissue. The dentist had not noticed this at the time,presumably because of his focus on the challenge of the extraction itself, and being under some stress knowing that a number of other patients were waiting to see him and that he was now running very late.
How was the situation managed?
The dentist immediately apologised and also contacted Mr K later on that day. As Mr K was grateful to have had the problematic tooth extracted, he did not take the matter further and accepted the apology.
• The dentist acknowledged that he had been so focussed on the challenging 27 extraction that he had forgotten the lower lip was also anaesthetised. As they were understaffed, he had been sharing a nurse with another clinician and usually his nurse would be on-hand to notice an event such as this. At the next practice meeting this incident was discussed and it was agreed the dentist should always be supported by a dental nurse when carrying out extractions and also to be mindful of the risk of soft tissue injuries to anaesthetised areas.
• Complications always seem to occur when there is time pressure. There should be protocols in place for managing such situations. In this case, a collective team decision was made that should a dentist run particularly late, patients would be advised of the delay and given the option to rearrange their appointments or be seen by another dentist if possible.
Case study – mechanical injuries
A newly qualified dentist mentioned to her principal that the fixation plate that attached the x-ray machine to the wall was not stable and when the arm was fully extended, the pressure on the plate caused some movement. The machine was wall-mounted to the left of the patient chair and had to be extended fully when taking radiographs on the right hand side. The arm was not stable at its full extension and would often drop after it had been aligned to expose the film. As a result, the final images were of limited diagnostic value as they did not capture the teeth and surrounding areas.
The young dentist asked for the fixation mechanism to be repaired or replaced.The principal resisted this and believed the dentist was over-reacting. He suggested an ‘alternative technique’ that he thought would remedy the problem. His solution was to forcibly wedge the collimator so it would sit next to the patient and the x-ray arm would not slip down.
The dentist called Dental Protection and a dentolegal consultant suggested the member put her concerns in writing to the principal. It was suggested her concerns could be justified by carrying out a risk assessment of the situation to identify what issues could arise and what harm could flow from a potential incident. It was also pointed out that should the dentist believe the working environment was hazardous,as she was controlling the handling of the equipment, it would be her responsibility to ensure it was safe.
Before the dentist could consider the advice further, she realised her next patient was due and required a radiograph. Unfortunately, the x-ray machine fell off the wall and took the surgery chair-light down with it, striking the patient on the head.
How was the situation managed?
The patient was able to have the x-ray in the next room and the principal immediately set about arranging for the x-ray machine and surgery chair-light to be repaired.
The principal recognised he should have immediately addressed the situation.The patient was not injured but was unsettled, and the practice called later on that day to ensure they were alright.
These case studies highlight the importance of team work, learning from mistakes and how risk awareness can reduce the number of injuries that are often avoidable.
Where risks can be avoided, such as the placement of a well-fitting rubber dam for all endodontic procedures, it is surprising why anyone would risk not doing so. Similarly, when equipment is well maintained this reduces the risk to staff and patients.
These examples demonstrate the value of a sincere and sympathetic apology and the importance of professional support. Although some patient safety incidents may require additional help in order to resolve the situation to the patient’s satisfaction, a telephone call following an incident can go a long way to convey care and indicate genuine concern, and can help reduce the chance of a patient taking matters further.
Whether it is in the form of professional advice, help with writing a response to a patient or assistance with arranging formal compensation, Dental Protection is here to protect the careers and reputations of members.