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System errors

  • Q
    A dental nurse colleague has failed to renew her registration with the GDC, but is still working clinically. Is my registration compromised if she continues to assist me in the surgery?
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    21 August 2014
    It has come to light that a dental nurse colleague has failed to renew her registration with the GDC, but is still working clinically. How should this situation be managed by the practice principal? In the meantime, is my registration compromised if she continues to assist me in the surgery?

     
    Clinical members of the dental team must either be on the GDC register or engaged in a course of training that leads to registration. The only exception to this rule would be where a dental nurse was waiting to start a training course for which s/he has registered. Clearly in the situation outlined here, the dental nurse meets neither of those criteria and s/he would then be vulnerable to an allegation of the illegal practise of dentistry.

    From the practice’s point of view, it should either suspend the dental nurse or move him or her to other non-clinical duties (reception, administration, etc.) until such time as they have been able to contact the GDC and their name once again appears on the DCP register. This usually takes a few days from the receipt of the re-application – provided there are no other significant circumstances.

    Allowing an unregistered dental nurse to continue working in a clinical setting would leave the dentist or hygienist open to criticism at the GDC.

    In reality both the dental nurse concerned and the practice should never have allowed the situation to occur in the first place. The GDC offers all registrants the facility of paying their registration fee by Direct Debit. It is advisable for a practice to keep a copy of every registrant’s current certificate of registration and also details of professional indemnity. The file of both documents can then be reviewed on a yearly basis.

  • Q
    An important piece of wall-mounted equipment in my surgery has been broken for some time. My practice owner says he will get it repaired but so far nothing has been done. What should I do?
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    18 August 2016

    Sometimes you may be concerned that patient safety is (or may be) seriously compromised by issues related to inadequate premises, equipment or other resources, or about the systems, policies or protocols you are asked to work to.

    Paragraph 8.1.1 of the GDC guidance advises that you must raise any concern that patients might be at risk ‘due to any aspect of the environment where treatment is provided’. This might include poor decontamination processes in your surgery or failure to maintain essential dental surgery equipment in good working order. Your first duty is always to act in the patients’ best interests and this means that you are under an obligation to take appropriate action which was initially to alert the practice owner. If the response is delayed, you could follow up the initial request, to get the equipment fixed, with an email or letter expressing your concern at the delay.

  • Q
    Could I be criticised for choosing an orthodontic aligner system if the company ceased trading and treatment was disrupted?
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    26 August 2014

    You could be criticised if you did not undertake ‘due diligence’ to satisfy yourself that the credentials, training and qualifications of the company’s employees’ opinions and recommendations were appropriate. Did you, for example, check if their name appeared on the orthodontic specialist register?

    The answer also depends upon whether or not the case(s) was suitable to be treated with aligners, or whether another orthodontic treatment approach might have been more appropriate. Further questions arise as to whether or not you considered (or discussed with the patient) these other treatment options, or perhaps different aligner techniques, and how well you documented these conversations in the clinical records, correspondence, etc. It may even be asked whether a specialist opinion should have been obtained.

    If it is subsequently alleged that your case assessment and/or treatment plan was negligent from a clinical perspective, this situation would be no different to any other orthodontic claim and would be managed as such. If it is argued that you could or should have known it was unwise to proceed with the use of this particular aligner system, much would depend upon when you started the treatment and whether or not you did so after rumours started circulating about the viability of the company in question.

    If you had sought and received reassurances in this latter regard, and were able to demonstrate them through records that you have retained, this may well be sufficient to deal with any challenge raised on that basis.

    Read our briefing document on this and associated aligner issues here [internal to position statement].

     

  • Q
    Do I need to have an automated external defibrillator in my surgery which exclusively offers treatment for children?
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    17 July 2014

    The Resuscitation Council UK’s guidance lists an automated external defibrillator as a minimum requirement. Although such guidance does not automatically create a statutory or mandatory obligation, a failure to follow the views of a reasonable, respected and competent body of opinion could be challenged. This would be particularly the case if a failure to use an AED on a collapsed patient can be shown to have had an adverse effect on the outcome.

    As an orthodontic practice your patients (and their parents, etc) may represent a slightly younger subset of the population when compared to a typical general practice. However, the guidelines draw no such distinctions.

    By failing to have this piece of equipment readily available, you would be seriously compromising your position in the event of a medical emergency.

    Click here for more information.

     

  • Q
    Even if it is only for a check-up and a scaling, do I need to provide a treatment plan and the cost of the treatment every time I see a patient and get them to sign it as well?
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    18 September 2014

    In business, it is always a good idea to ensure that people who are making a purchase are made aware of the costs involved before agreeing to go ahead. In this way, any misunderstanding about the price can be eliminated. By displaying a price list in the practice and on the website the curious patient can gain some idea about the cost of the initial examination. Indeed it is a good idea to tell all patients if the price list has been updated and to offer them a printed copy or indicate where it can be viewed. They should be encouraged to review it before seeing the dentist and for the avoidance of doubt, the cost of the examination (and any other requested treatment such as a scale and polish) can be included in the confirmation of the appointment and a note to this effect included in the patient’s record.

    Although patients may also be able to see the prices of an x-ray or other items of treatment they will not necessarily know how many x-rays and what sort of films will be required, or indeed what other treatments might be clinically necessary and to which they will need to consent.

    Any treatment plan that is proposed at the time of the examination needs to be discussed and priced accordingly and the patient should be handed a written summary which they can sign. The signed treatment plan is kept in the patient record and a copy is handed to the patient. This is important because many patients like to discuss treatment with friends and family, particularly if it involves significant cost. There are also patients who will need to share this information with carers, parents or guardians in order that they can involve them in facilitating their treatment.

    In addition to explaining the cost of the treatment, section 1.7 makes it clear that the patient must be told clearly which elements of their treatment are available on the NHS and which are only provided on a private basis. The GDC includes a clear instruction not to pressurise or mislead patients over treatments that should be available to them on the NHS.

    There is a co contractual requirement under the NHS to provide estimates for:

    • All band 2 and 3 treatments
    • When mixing NHS and private treatment
    • Band 1 treatments upon request

    Most modern computer systems and printers make it possible to provide a suitable priced treatment summary that complies with the GDC’s guidance.

  • Q
    How can I ensure the patients’ interests when I am working in a busy practice which offers a monthly bonus when we achieve the productivity target set by the owners?
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    18 September 2014

    This standard puts the interests of the patient as paramount when any decision is made about treatment or decisions about referrals. The GDC and the public will expect that any conflict will need to be resolved in favour of the patient.

  • Q
    I have issues regarding infection control in the practice. Where do I stand?
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    29 July 2014

    The senior partner says he recognises the British Dental Association’s infection control guidelines but because they are ‘guidelines’ they can be interpreted as he sees fit. Where do I stand?

    In some respects what the senior partner says is correct. However, there is no guarantee that the individual’s interpretation of these guidelines will be correct, or that the dentist would be able to defend that stance, particularly if the rest of the profession did not agree with that interpretation.

    In many situations, the BDA guidelines are not really open to interpretation. They represent good clinical practice and demonstrate a standard that would be regarded as appropriate. Generally speaking, the guidelines are realistic and take account of the difficulties that most clinicians face in their practices. They are by no means fixed, and indeed the guidance is regularly updated.

    The GDC guidance clearly indicates that a clinician must place the best interests of a patient first. If patients are perceived to be at risk, and the principal will not agree to alter the cross-infection procedures, the DCP would have to think carefully about whistleblowing. Indeed to fail to do so might mean that criticism would be levelled against the DCP.

    The decision to raise concerns is a personal responsibility. Most clinicians, when faced with a similar situation, vote with their feet and simply look for another job, arguing that they cannot work with the individual. Although this is disappointing and effectively ducks the issue, it also reflects the reality of human nature.

    Before making any decision, it is best for the DCP to speak with a defence society and ask for guidance. Every case will be different and there is no single answer that will fit every occasion. Doing nothing, however, is not an option. 

  • Q
    I often work with a trainee nurse who has not completed her course of Hepatitis B vaccinations. Is this ok?
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    31 March 2015

    A dental nurse, whether qualified and registered or a trainee, working in a clinical setting should not only be Hepatitis B vaccinated but must have clear proof of antibody titre to confirm that he or she is appropriately protected from the virus.

    The reasons for this are twofold:

    1. The individual must be protected (to protect themselves and their partner/family)
    2. Without vaccination, the dental nurse runs the risk of becoming infected with hepatitis which could then put patients at risk, which would be entirely contrary to the General Dental Council’s ethical guidance

    Anybody working with you chairside must be able to demonstrate that their Hepatitis B immunisation has been completed and that they have the required antibody titre. If this is not the case, they should not be assisting you in the dental surgery. You should discuss an alternative solution (perhaps agency staff) with the practice manager.

  • Q
    I undertake visits as part of my job and wondered if it's necessary to carry the same emergency drugs that I keep in the surgery?
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    19 August 2014

    Would I need to do this if I was visiting a nursing home with its own supply of emergency drugs?

    When carrying out home visits for patients, you should make every effort to ensure that the patient will not be disadvantaged by having treatment carried out in an environment which is not a normal dental practice.

    Consequently, you should always carry emergency drugs and oxygen, etc. If visiting a nursing home that has its own drugs and portable oxygen, it would be reasonable to accept that situation but always to ensure the drugs are in date and adequate for emergency purposes.

  • Q
    I've been told that every dental practice must appoint a first-aider. Is that correct, and what happens if the first-aider has time off? Is it illegal to continue working?
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    17 August 2016

    The Health and Safety (First Aid) Regulations 1981 require all business premises to provide adequate and appropriate equipment, facilities and personnel to enable first aid to be given to employees if they are injured or become ill at work. There is a separate requirement in any dental setting in the UK to ensure that appropriate CPR and medical emergency training has been undertaken by all registered dental professionals as well as other practice staff. The GDC recommends that registrants should undertake training about medical emergencies every year.

    In order to comply with the Regulations, the practice must first be assessed as to whether it is a low, medium or high risk environment. A dental practice would probably be assessed as medium risk, bearing in mind the training associated with the roles of the employees.

    The minimum first-aid provision on any work site is:

    • A suitably stocked first aid box
    • An appointed person to take charge of first aid arrangements

    An appointed person is someone who is chosen to:

    • Take charge when someone is injured or falls ill, including calling an ambulance if required
    • Look after the first aid equipment, e.g. re-stocking the first aid box

    However, this role is separate, and over and above, to the requirement for all the staff to participate in regular training for medical emergencies including CPR. 

    For dental practices assessed as medium risk and employing fewer than 20 people there should be a minimum of one appointed person. If there are more than 20, or the practice is assessed as hazardous, then a first-aider should be appointed.

    A first-aider is someone who has undergone a training course in administering first aid at work and holds a current first aid at work certificate, and will need to participate in regular training for medical emergencies including CPR.

    These requirements in terms of risk and numbers of employees are suggestions only and not definitive legal requirements. It would be desirable in any event for at least one practice member to have first-aider training, but the qualified first-aider does not need to be on the premises at all times and there is no recommendation to have one for a business with fewer than 20 employees.

    Further details are on the HSE website 
  • Q
    My practice principal is reluctant to employ an agency nurse when my dental nurse is off sick, so I must treat patients on my own. How should I deal with this?
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    15 September 2015

    To a large extent the problems you have are a contractual matter between you and the practice and therefore very much depend upon the associate agreement you were provided with when you started work.

    Assuming this is a standard associate agreement, you should find there is a clause within that agreement indicating that the practice is required to provide you with the services of a dental nurse on a day-to-day basis. The only time when this would not be the case is when exceptional circumstances exist (sudden illness, etc).

    The General Dental Council’s guidance clearly indicates that all clinicians should work alongside another team member (preferably a registered dental nurse) at all times. This is not necessarily a matter of chaperonage, but in fact relates to the provision of medical emergency care to patients.

    If one of your patients was taken ill during a treatment session and perhaps lost consciousness, you might find yourself facing the dilemma of either looking after the patient or going for help. You could not do both if you were working alone. If a dental nurse was working with you, this would not be the case.

    It follows that if such a situation was to arise, you might have to explain perhaps to the coroner, the courts or the GDC why a dental nurse was not present with you in the surgery, in accordance with GDC guidance. This would not be easy, particularly if it could be shown that the patient had suffered harm through lack of emergency care.

    You should discuss your concerns with the practice owner and practice manager and ask them what action they feel they can take to be of assistance to you. Your associate agreement likely contains a contractual obligation (to say nothing of an ethical obligation) on behalf of the practice to try to ensure a good working environment.

    If the problem continues or shows no signs of resolving, you may have to consider your position at the practice.

  • Q
    Should I refuse to see any patients (and cancel their appointments) in the absence of a registered nurse?
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    27 August 2014

    I am an associate working in a small practice. In the past, if a dental nurse was off sick the practice manager (who worked as a dental nurse for many years) would work with me, but she is not registered with the General Dental Council. If the situation arises again, should I refuse to see any patients (and cancel their appointments) in the absence of a registered nurse?

    In the event of your registered dental nurse being unwell, anyone standing in for her would either need to be registered with the GDC or in training for a registrable qualification. The GDC’s guidance states that when treating patients you must make sure there is someone else present in the room, preferably a registered team member who is trained to deal with medical emergencies. This might well mean cancelling patients, if for example you are unable to treat your patients safely and effectively without a nurse and a registered agency nurse could not be employed at short notice.

    It is sensible to have a contingency plan in place. The law states that it is illegal for a non-registered person to be involved in the actual practise of dentistry and the GDC has been quite clear that to allow a non-registered person to assist in the surgery could lead to an investigation into your fitness to practise.

    You can find out more about the indemnity obligations for agency-based dental nurses here:

  • Q
    What should I do if the dentist involved in a complaint is away on holiday and I am unable to stick to the time limits described in our practice complaints leaflet?
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    19 September 2014

    The GDC doesn’t define specific timings for managing a complaint but it does expect you to respond to complaints within the time limits that the practice has set out in its own complaints procedure. The NHS has its own guidance on limitations for dealing with complaints and these can vary according to the country you work in.

    Read our advice booklets on complaints handling

    Sometimes things can take a little longer to investigate, particularly if key staff members are on leave or off sick. If you find that need extra time to investigate a complaint, you should tell the patient when you anticipate being able to respond. If there are exceptional circumstances which mean that the complaint cannot be resolved within the usual time scale, you should give the patient regular updates (at least every 10 days) on progress.


  • Q
    Working as an associate, do I need to register as a data controller for the patient records that I handle?
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    29 July 2014

    It is difficult to give an unconditional answer as to whether an associate needs to register with the Information Commissioner. The British Dental Association advises that in its interpretation, associates are data controllers since they are responsible for their patients’ clinical records, as well as the manner in which the processing takes place.

    While the requirement for registration could potentially be countered by seeking to argue that practice records are the property of the practice owner, Dental Protection considers this interpretation could be open to challenge. If in the course of practising dentistry, you provide treatment as a performer under the NHS with no element of private practice, there could be an argument that you are processing data on behalf of the practice. However, if you are providing any element of private treatment, Dental Protection considers this interpretation may not be able to be supported.

    Additionally, if you are seeking to provide services as a self-employed practitioner rather than as an employee, you may consider registration with the Information Commissioner’s Office [http://www.ico.org.uk/] is just one feature that goes towards establishing your self-employed status for tax purposes.

    While it may be possible to successfully argue that associates do not need to register individually, on balance you might decide the benefits of incurring the small annual fee as a business expense outweigh the potential issues that could arise should you be challenged.