Wherever you are in the world, there is generally a legal obligation in place that sets out the duties of employers to ensure appropriate standards of quality and safety in a dental practice. Here Dr Simrit Ryatt, dentolegal consultant at Dental Protection, looks at iatrogenic injuries and what can be done to avoid them.

Legal obligation can include a delegable duty to team members to make sure equipment used in treatment is safe and maintained in good working condition, in accordance with the manufacturers’ instructions. It is, nevertheless, important to emphasise that it remains the responsibility of the clinician who is handling a piece of equipment to ensure a patient is not inadvertently harmed, either by operator carelessness or equipment malfunction.

Experience is generally a good thing, as you become more comfortable with dealing with challenging situations throughout your day. It is also worth bearing in mind that an experienced clinician may subconsciously become complacent about the risk attached to hazards in a dental surgery – particularly where the risk has been identified but not corrected.

No matter how proficient you are, there are some scenarios that are impossible to predict and are not under your direct control, such as sudden movements, or the behaviour of a patient. Therefore, it is important that we manage risk by focussing on the variables we can control, by ensuring that a regular risk assessment of surgery equipment and operative procedures is carried out.

A good example of how this may be put into practice is to plan procedures in advance and adopt a checklist approach to ensure that the required materials and equipment are readily available and on hand.

It goes without saying that personal protective equipment at work protects the members of the dental team and the patients. All members of the dental team play a part in identifying hazards and risks and reporting them before they cause injury. Risk assessment and reporting should be discussed at team meetings and follow-up actions should be notified to all team members. It is also important to keep a record of these discussions for future reference.

To help your understanding of how incidents can occur, here are some case studies you may find useful, and the learning opportunities each incident provides.

Case study: A laceration following an ultrasonic scale

A professional opera singer attended his hygienist for his regular periodontal treatment. He preferred to have local anaesthetic administered when he was receiving deep root debridement and always struggled with treatment when the lingual surfaces of his lower molars were cleaned. He found it difficult to breathe and it triggered his gag reflex. Midway through the appointment the dental hygienist was debriding the lower lingual area and the patient experienced an exaggerated gag reflex. As a result, the patient drastically moved so the hygienist immediately stopped. It became evident there was an intraoral laceration at the floor of the mouth that was profusely bleeding.

How was this managed?

The hygienist explained what had happened to the patient and applied pressure with a gauze. However, the laceration was still freely bleeding after ten minutes. The patient was beginning to panic, so a dentist colleague was called on to provide a second opinion and a decision was made to suture the area. A review appointment was arranged, and the patient was contacted by telephone later in the evening, who advised he was experiencing swelling of the floor of the mouth, along with some discomfort.

At the review appointment

At the subsequent review appointment, the wound was assessed, and the sutures removed. The injury was iatrogenic, caused by an error in the technique and, as such, the risk of this type of injury had not been discussed.

The patient subsequently had to take a week off from work and had to cancel performances. Although he had a good relationship with the clinician, he advised the hygienist of his intention to claim for compensation for pain, suffering and loss of earnings.

The hygienist contacted Dental Protection and our team was able to negotiate an early and appropriate settlement, protecting the member’s position and avoiding any risk of escalation.

Learning point

Although the hygienist was very experienced, the error was attributed to a lapse of concentration, which had unfortunate consequences. His reflection and subsequent analysis were recorded and shared with the rest of the team in the expectation that a similar situation may be prevented in the future.

Case study: A burn injury to the lip during tooth scaling

A dental hygienist working in a busy clinic had been moved into another room as some equipment in her usual room was broken. This was only realised at the start of the day and the hygienist had to swiftly set up in a room she was unaccustomed to. She was conscious she had a full list of patients and was already running late with three patients waiting. 

The first patient wanted a routine teeth-clean that day as she was due to get married the next week and wanted clean teeth for her special day. The hygienist brought the patient in and started the treatment. The hygienist could see that only a small volume of water seemed to be flowing from the scaler tip. She attempted to adjust the water setting and the scaling continued. However, the patient screamed loudly causing the hygienist to immediately stop. The water volume had inadvertently been further reduced and a small burn mark at the corner of the mouth could be seen.

How was the situation managed?

The hygienist apologised and a cold pack was placed on the area. The patient’s partner joined her in the surgery and although they accepted the explanation at the time, they called later that evening to complain.

A couple of weeks later, the wound had healed fairly well, but there was a faint scar that could be seen in some of wedding photos and the patient had said the scar had ruined her perfect wedding day. The hygienist and her clinic agreed to arrange treatment for her with a plastic surgeon and they were informed there was a good chance the wound would heal completely with minor surgery.

The patient went on to claim for compensation. Although the hygienist had expressed her regret at what had happened and arranged for further specialist care, there was still an expectation that the exercise of a reasonable standard of care would have meant that such an injury would not have occurred.

Learning point

A team meeting was held following the incident, and everyone acknowledged how potentially easy it was to cause such an injury, especially when working in an unfamiliar room. The team realised that special training needed to be provided for the team clinicians as each room had different equipment. In recognising the risk, the team were able to avoid future occurrences.

Case study: Mechanical injuries

A newly qualified dental hygienist mentioned to her principal that the fixation plate that attached the x-ray machine to the wall was not stable and when the arm was fully extended, the pressure on the plate caused some movement. The machine was wall-mounted to the left of the patient chair. It had to be extended fully when taking radiographs on the right-hand side. The arm was not stable at its full extension and would often drop after it had been aligned to expose the film. As a result, the final images were of limited diagnostic value as they did not capture the teeth and surrounding areas.

The hygienist asked for the fixation mechanism to be repaired or replaced. The principal resisted this and believed the hygienist was over-reacting. He suggested an ‘alternative technique’, which he thought would remedy the problem. His solution was to forcibly wedge the collimator so it would sit uncomfortably next to the patient and the x-ray arm would not slip down.

The hygienist contacted Dental Protection and a dentolegal consultant suggested the member put her concerns in writing to the principal. It was suggested her concerns could be justified by carrying out a risk assessment of the situation, hypothesising what could go wrong and what harm could flow from a potential incident. It was also highlighted that should the hygienist believe the working environment was hazardous, as she was controlling the handling of the equipment, it would be her responsibility to ensure it was safe.

Before the hygienist could consider the advice further, she realised her next patient was due and required a radiograph. Unfortunately, the x-ray machine fell off the wall and took the surgery chair-light down with it, striking the patient on the head.

How was the situation managed?

The patient was able to have the x-ray in the next room and the principal immediately set about arranging for the x-ray machine and surgery chair-light to be repaired.

Learning point

The principal recognised he should have immediately addressed the situation. The patient was not injured but was unsettled, and the practice called later that day to ensure they were alright.

Summary

These case studies highlight the importance of teamwork, learning from mistakes, and how risk awareness can reduce the number of injuries that are often avoidable.

These examples demonstrate the value of a sincere and sympathetic apology and the importance of professional support. Although some patient safety incidents may require additional help to resolve the situation to the patient’s satisfaction, a telephone call following an accident can go a long way to convey care and indicate genuine concern, therefore helping to reduce the chance of a patient taking matters further.

Whether it is in the form of professional advice, help with writing a response to a patient, or assistance with arranging formal compensation, Dental Protection is here to protect the careers and reputations of members.