A dentist discusses treatment with a patient in a dental chair.

Case Study: The Right Way to Avoid a Claim

Case studies often focus on what went wrong - but this time, it's a story of what went right. The documentation and actions taken by Dr. Henry and his staff prevented what could have been a very costly settlement.

Dr. David Henry was an experienced, AEGD-trained general dentist working with a partner in a small group practice, Renova Dental, where Marilyn and Leonard Ball had been patients for less than a year. Both Marilyn and Leonard were retired, active and in their late 50s, and both generally healthy. Per his initial health history, Leonard had mild, controlled diabetes and asthma.

The Recommendation

Shortly after becoming a Renova patient, Leonard inquired about options to restore his full mouth. Dr. Henry acquired a panoramic radiograph, and scheduled a consultation, which was held on April 25. At the appointment, they discussed the upper and lower arches separately, and the risks and benefits of implants, dentures and of not getting treatment. Leonard decided to proceed with the extraction of 12 upper teeth and placement of an upper denture. They also discussed the procedure, Leonard’s health and medications, and as per Dr. Henry’s process, that there would be a couple of preoperative appointments. They decided to wait to make a final decision on the lowers.

Shortly afterward, Leonard scheduled a sedation consultation for May 10, a June 21 preoperative visit and a June 28 date for the procedure. At the sedation consultation, Dr. Henry reviewed Leonard’s detailed health and current medication information, including his classification as an ASAII patient, his daily medication regimen and whether he takes his medication as recommended, baseline vitals including O2 saturation, pulse and blood pressure and an assessment of his airway. Dr. Henry explained Leonard’s procedure in more detail and gave him pre-operative and post-operative instructions, as well. Leonard was also given a printout of medication interactions at that appointment, which was included in his chart. He was advised not to use his nasal spray the day of the procedure.

Leonard was provided with an informed consent form for the sedation and the procedure itself—both were signed by Leonard, as per the process at the end of that visit. One form encouraged Leonard to call with any questions prior to the procedure. A detailed in-office form, signed by Dr. Henry and the assistant, outlined most all of the specifics of the appointment and was part of the record, as was a detailed progress note documenting this appointment.

On June 2, Leonard prescriptions were called in for pre-medications. On June 21, he came in for a vitals appointment and all were normal. The notes indicate he was approved for the procedure June 28.

The Appointment

On June 28, Leonard and Marilyn came to the appointment. The record contains both a detailed operative note, as well as a detailed progress note. Leonard’s heart rate and blood pressures were checked immediately prior to starting the procedure, as well as his oxygen saturation level. The patient confirmed he was NPO in the eight hours before the appointment, other than water and the pre-medication Triazolam.

Specifically, prior to and through the start of the procedure, continuous monitoring throughout sedation included:

  • O2 saturation
  • ECG
  • Capnography
  • O2 was given via nasal cannula.
  • Blood pressure was taken at 5-minute intervals.
    • The operative note shows the procedure began at 2:06 p.m.
    • There are entries on Leonard’s vitals and condition noted at 2:36, 2:39, 2:45, 2:50, 2:55, 3:03, 3:04, 3:15, and 3:20.

A staff person trained in life support was present. So Leonard was minimally sedated by.25 mg of Triazolam (taken one hour prior to the procedure), and the IV was placed. Once in place, he was given 100 mcg Fentanyl, then the Toradol and Decadron, and then the 2 mg of Versed (1 mg each, 2 minutes apart). The patient was then given 2 carpules of 4% Septocaine maxillary infiltration. #14 and #15 were removed. 2.5 carpules of 4% Septocaine were then given in the anterior for removal of #6 through #11. While giving a palatal injection, the patient expressed verbally that he wanted to be more sedated; 5 mg Versed was then given. 

After the removal of #6 and elevation on #5, or while working on the ninth of the 12 teeth to be extracted, Leonard coughed, coughed some more and then asked for his inhaler, which was in the room, and at his side. Leonard was given — and used — the inhaler. He, however, continued to cough and used his inhaler again. He then asked for a breathing treatment from Marilyn, who was in the reception room. She was immediately brought to the operatory room and gave him the breathing treatment. He was sitting up. Within less than 5 minutes, Dr. Henry realized that the breathing treatment was not alleviating Leonard’s cough.

The 911 Call

At that point, Dr. Henry asked the staff to call 911 because they could not control Leonard’s intense coughing. While the paramedics were in route, the breathing treatment was completed and O2 was continued through a nasal cannula. Leonard’s uncontrollable coughing continued until the paramedics arrived and while they were at Dr. Henry’s office according to Dr. Henry's progress note on the events. Leonard was starting to turn cyanotic and they were using verbal stimulation to keep him breathing.

When the paramedics arrived, Dr. Henry explained that he wanted to give Leonard .2mg of Fluazenil IV — a benzodiazepine antagonist — and 1 mL of 1:1,000 epinephrine and with the paramedics’ knowledge and agreement, he did so. A bag mask was placed and with the paramedics present, over the next 10 minutes, Leonard looked better with better color and temperature. Leonard’s oxygen saturation level improved and by all accounts, Dr. Henry, the paramedics, and Leonard’s wife, he appeared more stable. The patient was then transported to the hospital by ambulance by the paramedics.

What Happened Afterward

Follow-up With the Family

Over the next couple of days, Dr. Henry followed up with Leonard’s wife, Marilyn, to see how he was doing, and to monitor his condition and provide support. Mrs. Ball told Dr. Henry that Leonard was initially sent to the ICU, and then to the respiratory unit. He was discharged three days later, in good condition.

In sum, the details of the IV for moderate sedation (conscious sedation) were as follows: Leonard had taken .25mg of Triazolam one hour prior to the appointment to alleviate anxiety related to the IV stick. Thereafter, in divided doses the patient was given:

  • 100 mcg Fentanyl
  • 2.5 mg Versed
  • 30 mg Toradol
  • 8 mg Decadron

After the paramedics arrived, and with their permission, the patient was given:

  • .2mg Flumazenil
  • 1mL of 1:1000 epinephrine

Discussion with staff

Given the seriousness of the event and the call to 911, Dr. Henry promptly discussed this case with his partners and management person so that they were aware of the sensitivity of the situation and knew to direct any questions or issues concerning Mr. and Mrs. Ball to him.

Contacted Insurance Carrier and Lawyer

He then contacted his insurance carrier about this event to get any guidance on what to do moving forward, as he was concerned about any repercussions. His carrier immediately put him in touch with a local attorney because the state in which Dr. Henry practices (as do many others) has a requirement for reporting these types of incidents. He and his lawyer promptly prepared the necessary response. A couple of months later, Dr. Henry got a request for records from a lawyer for Leonard Ball. He and the Renova staff gathered and produced his records and asked his lawyer to help assure all was properly provided.

Monitored Patient's Account

Around this same time, the office manager, who was involved in the discussions about what had occurred, noticed that Marilyn Ball had not shown up to an appointment. She brought it to Dr. Henry’s attention and they worked together to prepare a personal letter to Marilyn as a reminder to reschedule the appointment and to wish both her and Leonard well. Dr. Henry asked his lawyer to review the letter before he sent it to ensure it struck the right tone. In that context, the office manager also noted that the Balls had an outstanding balance with Renova of $320. They spoke with counsel about what to do with that unpaid amount and on their lawyer’s advice, decided to write it off without further action so no inadvertent communications about collections would go to Leonard and his wife.

The state disciplinary board determined a few months later that there was no action warranted on the details or reporting of this incident. No lawsuit was ever filed.

What Can We Learn?

In hindsight, what factors helped to preclude a lawsuit or a disciplinary action? There were a number of factors that helped to establish that Dr. Henry and Renova acted appropriately in Leonard’s dental care, with the board, and with their interaction with Mr. and Mrs. Ball.

Thoughtful approach and treatment. The documentation in the records establishes, well before the procedure, that there was a thoughtful, detailed approach to this treatment plan and procedure, beginning with the first consultation appointment. A sit down to discuss the planned care, with notes to reflect the discussion, starts the process of informed consent. That process here included progress notes identifying discussions, signed consent forms executed well before the procedure date and notes reflecting that questions were encouraged.

The sedation appointment, detailed in both form and content, shows the thoughtful approach by Dr. Henry to the assessment of Leonard’s health history, the planning for sedation and the procedure and the assurance that Leonard was an integral part of this pre-surgical work up and care.

Clear Records and Documentation. Next, the records were clear on assessment of his pre-surgical physical condition with baseline vitals, and a confirmation of that condition was done on the specific pre-surgical vitals appointment a week before surgery. Dr. Henry’s records were very well-detailed to the specifics and the narrative of events. The detail and information in his records—to even the jaded eye of a plaintiff lawyer—told a story of a thoughtful, competent practitioner and the resources available for help if more questions or issues arose.

Clear Communication. Dr. Henry was upfront with his partners and key office staff concerning this event, directions for what to do if there was contact and how to move forward with guidance from both his carrier and counsel. These quick consultations helped relieve some of the stress, ensure that the proper laws and regulations were complied with and considered in context of a possible lawsuit down the road. Collaborating with the staff helped them be alert to questions or concerns, such as the no-show and outstanding bill, which can be very sensitive matters in a situation like this. The emphasis on practicing a team approach within the office helped to maintain consistency and improve upon office processes.

Follow-up and Support. Last, but by no means least, Dr. Henry’s care for his patient was evidenced by the emotional support he provided after this event, and guided by counsel of others who have experience with these types of situations (here the carrier and lawyer). When a practitioner demonstrates care and concern, it goes far to help avoid later litigation. All of these factors served Dr. Henry and put the practice in the best possible position to prevent a claim or disciplinary action, or defend against a claim if need be.

Linda J. Hay is a partner in the Chicago office of HeplerBroom, LLC. Ms. Hay has practiced in the professional liability defense arena for more than 25 years and has tried numerous cases to verdict. She is actively involved in a variety of defense bar, professional liability and risk management organizations. Ms. Hay can be reached at Linda.Hay@heplerbroom.com.

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