Mistakes can be made when writing referral letters, double checking the details can only help avoid anything like this happening...
Care should be taken when writing a referral letter. The specialist will rely on the letter to provide all the necessary information. This case resulted in two incorrect dental extractions being carried out because the referring practitioner, an orthodontist, had used a ‘carbon-free’ type of referral sheet to request the extractions.
The sheet contained a blank grid on which the orthodontist would indicate which teeth were to be extracted. Unfortunately, the bottom copy had slipped, the orthodontist didn’t notice and the instruction to the surgeon appeared to request the extraction of 24 and 34, not 14 and 44.
Nobody realised what had happened until the patient returned for treatment to the orthodontist, who was horrified to find the wrong teeth had been removed. Once the records had been reviewed and the error identified, the source of the error became clear. A discreet out-of-court settlement was arranged and the orthodontist modified her treatment plan in the light of this event to contain the damage done.
All referral requests should be reviewed to ensure they contain the correct information. This should be done before providing a copy of the referral to the patient (so they understand what they are being referred for) and storing a copy of the request in the patient’s record.