Checklist: Top 10 Risk Areas

Malpractice lawsuits don't always arise because of major mistakes or gross negligence. In fact, statistics show that malpractice cases typically stem from simple oversights and common errors that can be easily prevented.

Now you can quickly pinpoint malpractice weaknesses with this convenient checklist. It’s an easy guideline to help you evaluate your current procedures and implement simple solutions to dramatically lower your risk of a lawsuit.

1. Do you have efficient check-in and check-out procedures, including guarding the patient's protected health information, greeting patients when they arrive and recognizing them when they leave?

YesNo

GOOD. ACTION REQUIRED. Establishing a solid relationship will enhance the rapport and keep communication channels open. By saying the patient's name, you are not violating HIPAA. However, you should be cautious when confirming the reason for the visit. Greeting patients, apologizing if they have to wait and thanking them for their visit can help build a good relationship. Patients typically don't sue healthcare providers with whom they have a good relationship.

2. Do you have comprehensive documentation on each interaction with the patient?

YesNo

GOOD. ACTION REQUIRED. Your best defense in a malpractice case is your patient documentation. Entries should be legible to anyone who reviews them. Your records should provide details about your treatment decisions. This ensures compliance with licensure and accreditation standards as well as evidence of care.

3. Do you regularly use informed consent forms?

YesNo

GOOD. ACTION REQUIRED. Informed consent is more than a patient's signature on a form. Before any treatment, your patient should understand: (1) nature of the treatment, (2) pertinent material risks for the treatment, (3) the possibility of any risk, (4) alternative treatments available and the associated risks, (5) consequences of going without the recommended treatment. Check your state's requirements with your local dental board.

4. Is there a system in place for triaging, documenting and managing telephone calls and messages?

YesNo

GOOD. ACTION REQUIRED. Telephone triage is essential to the delivery of quality healthcare. Staff should be trained in telephone triage and authorized to interrupt the dentist or dental assistant when appropriate. Only qualified individuals should provide telephone triage services. Office protocol should require documentation of all clinically relevant telephone encounters (regardless of who places them or where they were received). Documentation should include the name of the person handling the call, details of the call and any advice, instructions, etc. This includes after hours calls.

5. Are new techniques closely monitored when implemented in your practice?

YesNo

GOOD. ACTION REQUIRED. Practitioners may learn new techniques or procedures and then try them out on patients immediately. It's crucial for your staff to integrate new techniques carefully. Only evidence-based techniques should be used in patient care. Also determine if the procedure is covered by your malpractice insurance.

6. Is equipment maintained regularly and documented? Is staff trained on the equipment to ensure safety?

YesNo

GOOD. ACTION REQUIRED. It is important to maintain a log of equipment checks and ensure that maintenance is consistent with vendor recommendations. Equipment should only be used by staff trained in its use if it is within their job description/scope of practice. Review training periodically to ensure equipment is used appropriately. If a piece of equipment is flagged as defective, notify our claims department once the equipment is moved to a secure location where it can't be used.

7. Do you have procedures for handling medical emergencies in your office?

YesNo

GOOD. ACTION REQUIRED. Emergencies can happen in any practice. You and your staff should be certified in basic life support. The office should have the minimum emergency equipment available such as oxygen, oxygen masks, bag resuscitator, oral airway, diphenhydramine and epinephrine and know how to use each. An emergency kit should be available, inspected and resupplied on a regular basis. Each staff member should know and practice their responsibilities so they are prepared in the event of an emergency.

8. Do you have written policies for staff that address areas such as credentialing, evaluations and job responsibilities?

YesNo

GOOD. ACTION REQUIRED. Written policies encourage standardization for patient safety and can prevent misunderstandings regarding job responsibilities and expectations. Policies should be clearly written so they are easily understood. Among other things, your policies should include the process of annually confirming licensing, continuing education required and received, and the scope of practice for each position. New staff members should be trained on protocols and all staff members should regularly review protocols and document the review.

9. Do you use a tracking system to identify when tests or consults are ordered and received?

YesNo

GOOD. ACTION REQUIRED. Missed test results can lead to diagnostic error, delay in diagnosis and delay in treatment. While missing test results can jeopardize patient care, lab results received but never reviewed by you or your staff can be just as problematic, especially when defending your care in a court room. A system to log and track tests and consults can help document informed refusal as well as information about results, advice or instructions provided to the patient.

10. Do you have guidelines when making referrals?

YesNo

GOOD. ACTION REQUIRED. Referrals are part of the overall patient management and should be made based on the patient's needs when you recognize treatment is beyond your scope of training or comfort level. Educating the patient about the need for the referral and then coordinating the appointment while the patient is in your office can encourage the patient to follow through with the referral. A tracking system should be in place to monitor referrals to assure a follow up report is received. Failure to coordinate care with other providers can set the framework for an adverse patient outcome. Communication is optimized by defining the role of each staff member for coordinating care, monitoring treatment and ensuring follow up when a referral has been made.

You may want to chat with a risk manager about any items you marked “no” on. Our experienced risk managers can help you assess your situation and suggest solutions you may want to implement to help minimize risk. Call the Risk Management Hotline at 1-844-208-7847 or contact us via email.