December 2016

Improper Preparation of Handpiece Results in Separation of Drill and Injury to Patient

Mario Catalano, DDS, MAGD

Background

Murphy's Law states that anything that can go wrong, will go wrong. Unexpected, negative events do happen in healthcare, including dentistry. However, as this edition of Malpractice Minute illustrates, when proper treatment protocols are in place and followed, the likelihood of Murphy's Law occurring is significantly reduced. Further, when the unexpected does occur, using proper preparations (particularly in the form of protocols) to manage such situations greatly increases the chances of a favorable outcome for the patient.

Case Discussion

The patient was a 33-year-old female who needed a dental implant to replace tooth number six. After being properly evaluated and consenting to treatment, she was scheduled for the implant placement with Dr. S, a general dentist who was new to practice. As part of his training and education, Dr. S had successfully completed an implant continuum.

Two certified dental assistants, who were employed by the same practice that employed Dr. S, assisted in the procedure. These dental assistants were very familiar with the protocol used. It involved establishing the osteotomy with a small implant drill, and then gradually increasing its size by using a sequence of progressively larger drills.

The procedure progressed uneventfully until one of the assistants failed to properly secure a drill in the handpiece motor. When Dr. S began to use the device, the drill separated from the handpiece motor and fell into the patient's throat, and the patient immediately swallowed it. Once it was clear that the drill could not be recovered, the procedure was aborted and emergency medical services (EMS) was summoned to the office. EMS subsequently transported the patient to a local emergency department (ED).

At the ED, an X-ray confirmed that the drill was in the patient's stomach. A gastroenterologist attempted to remove the drill, but was unsuccessful. The patient stayed overnight in the hospital so the progress of the drill going through her gastrointestinal (GI) tract could be monitored. The drill moved through the GI tract uneventfully, so the patient was discharged the following day. She subsequently passed the drill without any difficulty.

The patient contacted an attorney afterward, and a malpractice lawsuit was brought against Dr. S and the practice. Ultimately, because the doctor's and assistants' actions were determined to be indefensible, a settlement was reached. The settlement was in the low range (between $0 and $20,000). Further, because the patient had to be hospitalized, a mandatory report was submitted to the state board of dentistry, which conducted its own investigation.

 


 

Risk Management Considerations

Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM

The swallowing or aspiration of portions of instruments, tooth or filling material, or other foreign material is not uncommon in dentistry. However, several things can be done to minimize its occurrence. The first (and probably the most obvious) technique is the use of a dental dam. When the patient can tolerate a dental dam and it is appropriate for the procedure, the risk of foreign object aspiration or swallowing is reduced to nearly zero.

However, a dental dam is not always a practical option. When a handpiece is used (regardless of the procedure), any attachment that is inserted into the handpiece must be properly secured. To check to see whether an attachment is secure, pull firmly on the attachment with two fingers, operate the handpiece for a brief period (10 to 15 seconds should be sufficient), and then insert the tool into the mouth. If practical, the more vertical that the patient can be in the dental chair, the less likelihood that the foreign material will migrate to the back of the throat (if a separation should occur).

As with many procedures, having a written protocol for the instrument preparation before a procedure is beneficial. Dental assistants should be familiar with and adhere to all protocol requirements. Protocols that are consistently followed soon become habits, increasing the likelihood that things will be done correctly in all cases.

The swallowing or aspiration of foreign material is a complication that dentists should be prepared to manage. If it does occur, the dentist and staff should first determine whether the patient is in any distress (particularly respiratory distress). If the patient is in distress, then the dentist and staff should contact EMS and attempt to make the patient comfortable (not increasing the patient's distress is imperative). EMS personnel will evaluate the situation and take appropriate action upon arrival.

If the patient is not in any distress, calling EMS is probably unnecessary. However, the patient should have a chest X-ray promptly to determine whether the foreign material is located in the GI tract or respiratory tract. If the material is in the GI tract, a "wait and watch" approach is likely best; however, this may not be the case if the foreign object has a pointed or sharp edge to it, such as an orthodontic wire or a burr with a point.

If the foreign material has been aspirated into the respiratory tract, an endoscopic retrieval will likely be necessary. An ear, nose, and throat (ENT) surgeon or other appropriate physician will generally perform this procedure in a hospital setting.

Foreign material generally can be retrieved from either the GI tract or respiratory tract without difficulty. The ENT surgeon or appropriate physician will need to determine whether it is in the patient's best interest to let the foreign material pass on its own or take the necessary steps to retrieve it.

Although cases such as this can be frightening, most are handled with relative ease and result in a good outcome for the patient.

Conclusion

Research in both medicine and dentistry has demonstrated that most healthcare-acquired injuries can be prevented when appropriate protocols have been developed, are in place, and are properly followed. However, eliminating all adverse events is unlikely. For this reason, dentists and dental staff also need well-designed procedures for managing possible untoward events, such as aspiration of foreign material. Appropriate preparation and training will support safe and efficient handling of these types of situations.

Question

What steps can a dentist take to minimize the possibility of a healthcare-acquired injury happening to a patient in his or her office?

 

*NO PURCHASE NECESSARY. The “Malpractice Minute Contest” is subject in all respects to the complete Official Rules available by clicking here, or by sending a S.A.S.E. to "Malpractice Minute Contest," c/o The Medical Protective Company Dental Team, 5814 Reed Rd., Ft. Wayne, Indiana 46835. Open only to an entrant who, as of the entry date, is a permanent legal resident of the 50 U.S.A. or D.C. who is at least 18 years old and a matriculated student at an American Dental Association-accredited dental education program. The Contest is void outside the eligible contest territory, and where prohibited or restricted by law. Entry period for a Contest installment begins at 12:01 a.m. Mountain Time ("ET") on the date of publication of Sponsor’s Malpractice Minute e-newsletter and ends at 11:59 p.m. ET on the 60th day of publication of such e-newsletter. LIMIT: One (1) entry per person or address (physical or email) per Contest installment. Entry method, limits, restrictions and instructions, and prize information, requirements and restrictions are set forth in the Official Rules. Sponsor: The Medical Protective Company 5814 Reed Rd., Ft. Wayne, Indiana 46835. Click here to view complete Official Rules.