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Would you like Endone on the side?

Post date: 18/09/2015 | Time to read article: 4 mins

The information within this article was correct at the time of publishing. Last updated 14/11/2018

As a fresh graduate, I started working in the public system in a small country town with another graduate and a mentor/senior dentist who would come by a few times a month to extract wisdom teeth.

The group practice consisted of GPs, allied health and oral health along with other community services. A patient came in with a partially erupted 38 which needed a surgical extraction and an appointment was scheduled with the senior dentist.

The day before the extraction the senior dentist stated he was unable to attend on that date and time and, despite efforts to contact this patient to reschedule his appointment, he was unreachable. The day of the extraction came and naturally the patient attended. The practitioner who originally saw the patient was running late and, as I was free, I offered to see him to apologise and explain the situation. The patient complained of severe pain resulting in limited opening and there was reddening and swelling of the operculum surrounding the visible portion of the 38.

I recommended a chlorhexidine mouth rinse and provided a monojet syringe for irrigation under the operculum. I also scripted paracetamol 500mg and codeine 30mg. As per usual with my scripts, I cross hatched the blank space at the bottom.

The next day I spoke to the pharmacy as they said there was more than one painkiller on the script; “You shouldn’t have put two S8s on the same script!” they said. I was confused about this and clarified that I only scripted paracetamol and codeine; I asked what else was on the script. The pharmacist said ‘Endone’ (oxycodone) and that he provided it to the patient in conjunction with the paracetamol and codeine.

It later become apparent that the pharmacist had suspected the script had been tampered with or falsified in the first instance and had called through to discuss this with me. Regretfully, they had contacted another department within the centre and for reasons unknown, this call was not transferred to me. Disheartened, the pharmacist had proceeded to issue the prescription in its entirety.

I was very upset and felt professionally violated, and immediately called Dental Protection’s dentolegal advisory service.

I was advised to telephone the police, prepare a signed written statement of my version of the events and cancel the rest of my patients for the afternoon as I was too upset to continue.

My dental assistant had gone to the pharmacy to obtain a photocopy of the script for our review. On looking at the script the patient had crossed out two words and slipped in ‘Endone’ in excellently forged handwriting. Despite the paracetamol and codeine both having dosages (500mg and 30mg) written next to them, the word ‘Endone’ had no dosage written next to it.

The police soon arrived and looked at the script, and then took the patient in for questioning. Despite initially warning that prosecution of the patient would be difficult because a copy of the original script was not available, the police were eventually able to obtain a full confession from the patient.

The principal GP of the practice has since taught me a better way of writing scripts in absence of a triplicate and recommended I number all items in future, and write in words at the bottom ‘total number of items: ONE’. I now do this religiously for all my scripts. The police also encouraged me to take digital photos of all future scripts for any future prosecution of fraud cases. I also found a Medicare fraud tip-off line for script fraud and I gave them the patient’s full details as well as a pledge to give evidence if Medicare proceeded with an investigation.

That’s not the end of the story. Two weeks later, the patient left the practice a voicemail, annoyed that we had not contacted him to reschedule his surgical extraction! We do have a duty of care to refer him appropriately but he is no longer welcome at our practice. To paraphrase the police: barring the patient from your practice will teach him far more of a lesson than our court system ever could!

The dentolegal adviser's perspective
Dr George Lazaridis

This example highlights an extremely difficult and upsetting time for any dental practitioner, regardless of their postgraduate experience. It is challenging enough to deal with the usual patient dilemmas day-to-day, let alone having to manage the often distressing interactions with third parties such as the police, or a regulator. 

Our young graduate did the correct thing by contacting a colleague immediately for support; always contact a dentolegal adviser if you have any issues or concerns regarding patient management as we are there to offer support and advice and most importantly help you through this difficult time until the matter is resolved.

In every clinical situation or patient interaction, you need to ensure that you have documented the events accurately and thoroughly and, in a situation such as this which escalated rapidly, you may wish to consider ceasing working until the situation stabilises. Trying to continue to work when you are acutely distressed may have disastrous consequences. 

Situations that place us at most risk are:

  • Emergency situations
  • When we are anxious or fearful
  • When we have difficult interactions
  • Where we are under time pressure
  • When we are hungry, angry, late or tired (HALT)

It can be a difficult call to cancel pre-booked patients, but always remember that the most important person in the room is the patient in the chair, and, if through circumstances outside your control you are unable to offer that person your full attention, you are best to defer until such a time that you can care for them in the manner they deserve.

These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits dental members enjoy as part of their subscription. 
For more detailed advice on any issues, contact us

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