November 2018

Dentist’s Inadequate Medication Instructions Lead to Poor Patient Decision-Making, Resulting in Severe Infection

Mario Catalano, DDS, MAGD

Background

Dental patients sometimes develop surgical site infections even though proper aseptic technique has been followed during their procedures. When this occurs, the dentist has an array of treatments from which to choose, normally resulting in minimal discomfort to the patient. The dentist should select the appropriate treatment and medications and provide the patient with clear and specific discharge instructions. Medication decisions should not be delegated to the patient. The following case illustrates what can happen when the patient is asked to make clinical decisions and judgments.

Case Discussion

A female in her forties was an established patient of Dr. G, a GPR-trained general practitioner who had been practicing in the Northwest for 3 years prior to this case. Dr. G had been monitoring the patient for a horizontally impacted tooth (tooth 32). A deep periodontal pocket was developing on the distal aspect of tooth 31, so the patient finally consented to the extraction of tooth 32. Dr. G referred the patient to a local oral and maxillofacial surgeon (OMS) for the extraction. However, the OMS was not in the patient’s provider network, so she asked Dr. G to perform the extraction. Because he had experience with this procedure, Dr. G agreed.

The procedure occurred on a Friday, and the sectioning and removal of tooth 32 were unremarkable. At the conclusion of the procedure, Dr. G gave the patient a prescription for pain medication and postoperative instructions that included the application of ice for the first 24 hours. Dr. G did not give the patient a prescription for an antibiotic because there was no indication for it at the time.

On Saturday, the patient still had some pain and swelling, so she applied ice as directed until her follow- up appointment on Monday morning. At that time, she continued to have mild pain and swelling at the extraction site. Dr. G gave her a prescription for cephalexin, with instructions to start it “if the swelling does not improve.” She was scheduled to come back on Friday of that week.

By the Friday appointment, the patient had significant swelling. She indicated that she did not begin to swell until Thursday evening, so she tried to call the office after hours, but her call was not returned. Not knowing for sure what to do, she didn’t start the cephalexin; rather, she waited to see Dr. G in the morning. Dr. G. attempted to incise and drain the swelling, but he could not locate the focus of the infection. He advised the patient to begin the cephalexin and also wrote her a prescription for clindamycin, with instructions to start it “if needed.”

By Saturday, the patient was in significant pain and having difficulty swallowing, so she went to her local emergency department. She was admitted and placed on IV antibiotics. An incision and drainage were unsuccessful; as a result, she ultimately underwent a tracheotomy and was placed on a ventilator. Fortunately, she fully recovered and had plastic surgery to correct the scar on her neck.

The patient filed a dental malpractice lawsuit against Dr. G. Although Dr. G’s malpractice insurer defended the lawsuit, Dr. G chose to pay the settlement (which was in the low range) himself.

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Risk Management Considerations

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

This case is interesting in a couple of respects. First, the majority (more than 60 percent) of cases filed against MedPro-insured dentists involve an allegation of improper technical performance of a dental procedure. However, in this case, the allegation was that the case was improperly managed. Improper management cases usually involve issues such as medication management (as in this case), systems failures, miscommunication between providers, and the like.

Second, the patient’s clinical situation probably could have been resolved quickly with good communication between Dr. G and the patient; however, it turned into something quite serious because the patient was not confident and/or knowledgeable enough to make a clinical decision on her own.

Ultimately, the mistake Dr. G made in this case was expecting the patient to determine when her condition had changed sufficiently to begin a prescribed therapy (i.e., antibiotics). This approach is unfair to the patient and unlikely to produce a good result in many cases. Often patients are either not self-assured in their decision-making, or they do not have the knowledge and expertise to recognize the indications for commencing therapy.

One way to address this issue is for the dentist to contact the patient on the evening of surgery to determine the patient’s condition. However, problems still can develop after that initial call; thus, a valuable second step is to give the patient a phone number at which the dentist can be reached, along with instructions to call if his/her condition does not improve or worsens. At that point, the dentist can determine whether the patient (a) needs to have his/her follow-up appointment moved up (or if another appointment needs to be scheduled), (b) needs to be started on a treatment regimen, but does not need to be evaluated in the office, or (c) requires no immediate action. In any case, a negative change in the patient’s condition is something the dentist needs to know about in a timely fashion.

Admittedly, a few patients may “overuse” this access; in all likelihood, though, at least as many (like the patient in this case) will be inclined to not want to bother the dentist. Few situations cannot be managed quickly and effectively — but only if the doctor is aware of what is happening. Communication is the key, and patients should be encouraged to voice concerns and clarify instructions.

Conclusion

Involving patients in shared decision-making and taking a partnership approach to patient care is valuable. Yet, bearing in mind the respective roles of the partners also is essential. Patients should never be charged with clinical decision-making, at least not in the absence of collaboration with the doctor. Such collaboration enhances the doctor–patient relationship and produces the best clinical results.

Question

In what circumstances should patients be involved in clinical-decision making regarding their own care (in collaboration with their dentists)?