VO: This podcast is intended to provide information only on certain risk management topics, and is not to be construed as providing legal, medical, or professional advice of any form whatsoever. Because federal, state, and local laws vary by location, nothing in this podcast is intended to serve as legal advice or to establish any standard of care. Legal advice if desired, should be sought from competent counsel in your state.

Host: Hello and welcome back to Forecast, the podcast designed to help dental professionals move forward in their practices. Brought to you by Fortress Insurance, the leading professional liability insurance coverage provider for dentists. Not familiar with Fortress yet, get in touch with Fortress and find an agent by visiting our website at dds4 dds.com. That's d-d-s, the number four, dds.com. I'm Dr. Julie Goldberg, the education program developer at Fortress. For those listeners who've been tuning into Forecast, welcome back and thanks for listening. And for those of you who are new, welcome to Forecast. We are so glad you've joined us. In our last episode, Kim Gensler, Director of Claims used an actual closed Fortress claim to highlight the benefits of involving patients in the informed consent process.

Kim returns for this episode and is prepared to discuss the patient's safety and risk management lessons from another closed fortress claim. Kim, welcome back.

Guest: Thank you, Julie. It's great to be back.

Host: Kim, in our last episode, you discussed the informed consent process in the context of a closed fortress claim. I understand that you have another claim to discuss today. What is our topic?

Guest: Today we will discuss the lessons learned from a closed claim, which involved a wrong tooth extraction. As with our prior episode, the facts have been de-identified and adapted for our educational purposes.

Host: Great, Kim, with that background out of the way, let's get started.

Guest: Absolutely Julie. This claim involves a woman in her forties who was referred to a Fortress insured dentist by her endodontist for extraction of non-restorable tooth number 25. The dentist's treatment plan included extraction of number 25 with a consideration for a future implant. After the patient was consented for the extraction of number 25, under local anesthesia, the dentist performed an extraction of tooth number 24, which as we know from the brief clinical facts was the wrong tooth.

As the dentist was entering the clinical documentation, the dentist identified that the wrong tooth was extracted, and immediately informed the patient. The patient agreed to proceed with the extraction of number 25 as had been planned, which was performed with no reported complications.

Host: Kim, this sounds like a challenging scenario for the dentist and a concerning one for the patient. What happened next?

Guest: The patient returned one week later and at this visit the dentist noted that the size of the patient's alveolar ridge likely would not support two anterior implants and instead recommended a four unit bridge to replace teeth numbers 24 and 25.

Host: We know that this patient eventually pursued a claim. What were the allegations here?

Guest: So in this situation, a lawsuit was never filed in court. This patient hired an attorney who made a direct request for compensation from the dentist in an effort to attempt to reach a resolution before formally commencing litigation. The insured dentist then appropriately contacted Fortress to assist with the response to this request.

The patient's attorney alleged that the dentist was negligent in extracting the wrong tooth. And that the negligence caused an injury to the patient. In this case, the injury alleged was the loss of an apparently healthy tooth.

Host: Kim, in prior Forecast episodes, we learned that Fortress utilizes a panel of practicing dental professionals as an important part of the claims review process. What did the panel's evaluation in this claim reveal?

Guest: In this claim, given that the dentist had conceded that the wrong tooth was extracted, it appeared likely that the patient's attorney would be able to meet the burden of proof in demonstrating both negligence and injury, which are the essential elements of a professional liability claim. Therefore, the Fortress Claims Review Committee recommended settling this claim. The dentist agreed and the claim was settled to include the cost of past and future treatments, pain and suffering.

Host: I can see how allegations of wrong site procedures, including wrong tooth extractions can be difficult to defend.

Guest: That's correct. These claims are challenging to defend and the best practice is for each dentist to employ strategies which ensure that the correct procedure is performed on the correct patient. Based on Fortress's experience, managing wrong site procedure claims, including wrong tooth extractions; a few strategies for the prevention of these claims can include; first, improving communication among a patient's providers. It's important to clarify any questions about the patient's treatment plan with any referring or treating providers before initiating your treatment. Second, improve communication with each patient. Communicating and engaging with your patients through the informed consent process may prevent wrong site procedures.

As a reminder from our last episode, the informed consent process involves a discussion with the patient about the planned treatment, a signed consent form, and clinical documentation, which supports the dentist's patient education and care coordination effforts.

Host: Communication is so important, Kim. Another example of improving patient communication is to have each patient confirm the treatment site by pointing, then the provider can confirm the patient's understanding aligns with the treatment plan, the clinical records, and the informed consent form.

Guest: That's right, Julie. And a third strategy to reduce wrong site surgeries is to ensure accurate imaging. When images lack diagnostic quality, are out of date, are not mounted or saved in the appropriate referential perspective or do not belong to the patient being treated, a stop to either obtain new or correct images can prevent wrong tooth extractions and wrong site procedures.

Host: Those recommendations make sense, Kim, do any other suggestions for reducing the incidences of these types of eventscome to mind?

Guest: Yes. The first is a consistent use of a timeout. In a hospital operating room, this is standard procedure before treatment begins and is used to confirm the accuracy of the patient's identity, the surgical site, and the planned procedure. Dental practices can implement the same process.

Host: That's a great point, Kim. In fact, Fortress offers a surgery checklist on our website to document the steps of a pre-procedure timeout. Do you have any final suggestions to share, Kim?

Guest: Yes. My final suggestion is a fundamental one that may at times be easily overlooked. When questions about a patient's procedure arise, the safest and most patient focused approach is to delay non-emergency treatment until those questions are resolved. Resolving these questions may include reviewing the clinical records and imaging, coordinating care with the patient's other providers, and then documenting these efforts in the clinical records.

Host: Thank you, Kim, for again, sharing the important lessons which can be identified from our closed claims.

Guest: Thank you again for the opportunity, Julie. It was great to be here.

Host: As we wrap up our eighth episode, I would like to thank our listeners. We appreciate you taking time out of your day to tune into Forecast. More information about Fortress and the available patient safety and risk management resources can be found on our website @ dds4dds.com. That's d-d-s, the number four dds.com.