Table of Contents

Title Page

Copyright Page

Foreword

Preface

Acknowledgements

Chapter 1 Understanding Risk

Definitions

Perceptions of Risk

Risk Categories in General Practice

Risk Communication

Risk Scales

A Clinical Perspective

Conclusions

Further Reading

Chapter 2 Principles of Risk Management

Core Principles

Aims of Risk Management

The Risk Management Cycle

Risk Identification

Risk Analysis and Assessment

Hazards

Risk Control

Health and Safety

Risk Transfer (Financing)

Managing Common Risks in General Practice

Clinical Risk Management

Conclusions

Further Reading

Chapter 3 Understanding Human Error

The Meaning of Human Error

Primary Care International Study of Medical Errors

The Swiss Cheese Model of Accident Causation

Active and Latent Failure

Error in Practice

Adverse Patient Incident and Harm

Adverse Events and Near-Misses

Predisposing Factors

Error Management

Root Cause Analysis

Poka-Yoke Devices

Chaos Theory

Conclusions

Further Reading

Chapter 4 Ethical Considerations

Ethical Relationship

Ethics and Complaints

Ethics and Philosophy

Consequentialism

Deontology

Ethics and healthcare

Ethical Guidance

Patient Autonomy – Self-governance

Nonmaleficence – Do No Harm

Beneficence – Do good

Justice – Fairness

Veracity – Truthfulness

Conclusions

Further Reading

Chapter 5 Consent and Communication

What is Consent?

Authority

Risk Management Tip

Capacity

What Affects Decisions About Capacity?

Age

Maturity

The Complexity of the Procedure

Temporary Incapacity

Common Pitfall

Providing Treatment to Patients Without Capacity

Paternalism v. Autonomy

Common Pitfalls

Information

A Case Scenario

Discussion

Autonomy

Common Pitfalls of Consent

Conclusions

References and Further Reading

Legal Cases

Chapter 6 Dentist-Patient Relationship

First Encounters

The New Patient Consultation

Risk Management Tip

Medical History and Documentation

Case Scenario

Discussion

Dental and Social Histories

Risk Factors

Patient-Oriented Red Flag

Previous poor dental history

Crusaders

Emotional baggage

Disproportionate expectations

Dictating and demanding people

Money Issues

Charging for everything

The patient who questions all accounts

The slow payer

Money is no object

The bad debt

Treatment Red Flags

Complex or difficult treatment

The potential for failure or decreased life-expectancy of the treatment

Potential for pain/aesthetics/functional problems

Skill and expertise

Multiple-visit treatment

Red Flag Dentists

A Risk Management Tip

Unconventional Views

The Source of Training

Administration Red Flags

Inadequate appointment times

Broken appointments and cancellations

Know the rules

Conclusions

Further Reading

Chapter 7 Clinical Records

What Constitutes a Clinical Record?

What Information Should be Included in the Record?

How Much Detail Should be Included?

Benchmarking

Written medical history

Audit

Omissions

Who Compiles the Records?

Falsification

What do I do if I make an error on the records?

Privacy and Access to Records

For How Long Should Records Be Kept?

Common Pitfalls

Computer Records

Common Pitfalls

Conclusions

Further Reading

Chapter 8 Clinical Negligence

Duty of Care

Standards of Care

The Civil Standard

Staying Abreast of Current Clinical Thinking

Conflicting Opinion

The Concept of Harm

What About Other Standards?

The Adverse Incident

Reporting Adverse Incidents

High-Risk Areas

Risk Reduction

Further Reading

Chapter 9 Handling Complaints

Opportunity or Threat

Why Do Patients Complain?

Seeking Feedback

Outcomes

An Outlet

An Explanation, an Apology or Reassurance

Appropriate Remedial Action or an Intention to Do So

Empathy

Redress/Recompense or Symbolic Atonement

Follow-up

Anatomy of a Complaint

Complaints Recovery

Internal Practice Systems

Ten Steps in Complaints Handling

Acknowledge and clarify the complaint

Investigate fully

Remain calm and in control

Find out what the patient wants

Take advice

Keep patients informed

Decide on a response

Agree action

Follow-up

Maintain confidentiality

Conclusions

Further Reading

Chapter 10 Business Risk

What is Business Risk?

Risk and Reward

Risk Mapping

Risk Assessment Map

Managing Business Risks

Quadrant 1: “Prevent at source” risks

Quadrant 2: “Detect and monitor” risks

Quadrant 3: “Monitor” risks

Quadrant 4: “Low control” risks

Reputation Risk

Media

Investment risk

Further Reading

Foreword

Risk is a fact of clinical practice, let alone life in general. Risk cannot be eliminated, but it can be minimised through risk management – understanding risks and overcoming them in a planned, positive manner. This carefully prepared, most welcome addition to the Quintessentials of Dental Practice Series provides a detailed understanding of the risks in general dental practice, together with a pragmatic, yet robust approach to risk management in the provision of dental care. Much of the text is relevant to practitioners and students in all aspects of dentistry.

As has come to be expected of additions to the Quintessentials of Dental Practice Series, this book is a very readable, well-produced mine of information and practical guidance. In a climate in which patients have increasing expectations of treatment and the complaint culture has grown exponentially, Risk Management in General Dental Practice is a timely publication. In the few hours it takes to read this book, much can be learnt and, more importantly, the reader can develop a road map to conceive, plan and implement risk management in their clinical practice.

Of the many insightful quotations included in the book, the one attributed to Leonardo da Vinci may be considered best to encapsulate risk management as promoted by authors: “think of the end before beginning”. If you and your dental team do not think this way, this book will be a revelation. If this does not encourage you to acquire and read this book, then turn to the contents page and dwell on your knowledge and understanding of the important topics addressed in this text. All those engaged in the clinical practice of dentistry would benefit from reading this book.

Nairn Wilson
Editor-in-Chief

Preface

To paraphrase Charles Dickens in A Tale of Two Cities – “these are the safest of times; these are the riskiest of times”.

In this book, our aim has been to address some of the broader aspects of risk management and to explore the framework principles which underpin risk management in general dental practice. In common with many other organisations and institutions, we recognise that the risks associated with the practise of dentistry are the result of:

• Consumer orientation – our patients behave as dental consumers who demand high-quality and high-value care.

• Litigation trends – when expectations are not met, patients are more likely to seek redress via the courts.

• Clinical governance – new pressures for increased accountability, performance and audit help to identify “quality gaps”.

• Financial pressures – there is a view that funding levels have not kept pace with advances in clinical practice and the associated costs. The result is a narrowing of the margins for error and inefficiency and a steady erosion of profit. This in turn can place the entire enterprise at risk.

We suggest that managing these risks should be an integral part of good business practice and believe that an effective risk management strategy can help to:

• Enhance the patient experience.

• Encourage a patient-centred approach to clinical practice.

• Promote a culture of safety within the practice.

• Inspire innovation in practice management.

• Lift morale amongst team members.

• Raise the standard of care.

• Improve clinical outcomes.

• Implement clinical governance.

• Improve compliance with professional guidelines.

• Increase efficiency in the practice.

• Introduce a high standard of accountability in the practice.

• Allow for more effective allocation and use of resources.

• Build a good reputation.

Studies have shown that healthcare professionals have been reluctant to admit and address the problem of errors, both because of feelings of guilt and from the desire to avoid peer disapproval and/or punishment. Attitudes are now changing and we hope that this book will help dentists better to manage the risks inherent in our daily practising lives.

We have deliberately discussed some aspects of risk management in a conceptual way to enable practitioners to contextualize those principles and would remind readers that legal citations, whilst accurate at the time of writing, may be superseded by future legislation.

Raj Rattan

Acknowledgements

My sincere thanks to those who willingly and unselfishly gave their permission to quote and reference their work. Their responses to my requests for information and advice were always positive and immediate; their individual contributions are cited in the text.

Raj Rattan

I am indebted to my good friend and colleague Lynn Walters who first inspired me to take an active interest in the dento-legal field. His advice, encouragement and guidance remain a precious asset for all those who know and continue to work with him. Thanks to Kevin Lewis for supporting this project and for allowing use of the images for the front cover. I would like to put on record the strength of the team he leads at Dental Protection Ltd. – their commitment to supporting and assisting our professional colleagues is unrivalled. My thanks to my co-author, Raj Rattan, for suggesting that we collaborate on this book – it has been an enjoyable and worthwhile experience.

On a more personal note, my thanks to my family Marie, Mark and David for their constant support.

John Tiernan

Chapter 1

Understanding Risk

Risk enters our lives from the moment of conception, from our first breath of air to our last. We spend our lives trading risks for rewards and each one of us trades from a different perspective. It can be said that:

• risk-taking is influenced by the rewards

• perceptions of risk are influenced by experience of losses – one’s own and others

• risk-taking involves balancing between the propensity to take risk and the perceived risk.

Definitions

Risk is the possibility of loss, injury, disadvantage or destruction. It is the probability that a given hazardous event will occur and that this event will have consequences, which are deemed to be negative by some, or all of those who are exposed to it.

People use the word “risk” in different ways and it is a widely misunderstood term. “Risk” is sometimes incorrectly used to mean the hazard itself such as in the statement: “The risk is that he will die skydiving”, or (correctly) risk can relate to probability as expressed in the statement: “The risk of dying from skydiving is small”.

Risk is the probability that a hazard will give rise to harm. It is not the same as uncertainty. Risk is when you don’t know what will happen but you do know the probabilities; uncertainty is when you don’t even know the probabilities.

We can define the terminology in the following way:

• Hazard – condition/circumstances with potential for causing or contributing to injury or death. A hazard is anything that might cause a risk.

• Risk – the probability or likelihood of injury or death.

• Danger – product of hazard or risk.

• Uncertainty – inability to make a deterministic prognosis.

Perceptions of Risk

In his book Risky Business Professor John Adams of University College London identifies three types of risk:

1. Directly perceptible risks – these are the risks we deal with instinctively and intuitively like crossing the road. In this situation, we become our own risk managers.

2. Risks perceived through scientific study – for example, the harmful effects of smoking and drinking on oral soft tissues can be understood through scientific study by examination of cellular changes. We know about these risks and we communicate them to our patients, but many patients will continue with their habits.

3. Virtual risks – these are culturally constructed when the science is inconclusive; it allows people to perceive the risk according to their pre-existing beliefs and prejudices. It also gives the media a freehand to write catchy headlines to attract readers’ attention. For example, many dentists have been asked about the alleged risks to health from mercury in dental amalgam and have experienced the perceptual variations amongst patients when discussing the issue.

These variations arise because the perception of virtual risks is altered by the way we view the world. Adams proposes a four-fold typology, which categorises people into different groups; this helps to understand the variations in perception (Table 1-1).

Patients’ reactions to risk often have their own rationality. In most dentist-patient interactions, the dentist is the expert and the patient the layperson. Dentists may spend time communicating with patients about the risks associated with poor oral hygiene; however, the patients may perceive the risk from a totally different perspective (Table 1-2).

Source: Based on slovic P. Trust, emotion, sex, politics and science: surveying the risk-assessment battlefield. Risk Analysis 1999;19:689–701.

We must learn to manage these perceptions in risk communication. Dr. Vincent T. Covello, an internationally recognised expert in the field of risk communication and Director of the Center for Risk Communication in New York, has identified the key factors that play an important role in the perception of risk (Fig 1-1). In a presentation at the Center for Risk Communication in 2002, Covello noted that: “There is virtually no correlation between the ranking of a threat or hazard by experts and the ranking of those same hazards by the public”.

Covello made it clear in his study that trust is a key element in the communication process – if patients trust the dentist they are more likely to take heed of risk communications. This is reflected in everyday practice where a patient who is presented with a range of treatment options with the pros and cons, will in a strong dentist-patient relationship request the dentist to undertake what he or she feels is “best” for them.

Risk Categories in General Practice

Kahn has suggested a list of risk criteria, which apply equally to general practice as to the hospital environment for which they were first identified. These are:

• potential for litigation

• possibility of erosion of reputation and confidence

• a breach/threat to security of premises, facilities, equipment or staff

• significant actual or potential injury to patients or team members

• minor incidents

• significant occupational health and safety hazards.

In his excellent book Risk Management in Dentistry Roger Matthews supports Kahn’s criteria and has written: “A practising dentist today will at some point be faced with a potential loss from an event meeting one or more of these criteria.” His words were penned a decade before the claims and complaint culture grew exponentially in the UK. The broad categories of risk affecting dentists in general practice are summarised in Table 1-3.

Risk Communication

Risk communication is about:

• Ensuring that our patients understand the meaning of our risk messages.

• Persuading patients to change or modify their behaviour.

• Creating the conditions for a two-way communication process as a means of addressing ambiguity.

We recognise that patients want to be informed about the risk factors associated with dental diseases and about risks associated with treatment provision, and we know we have an ethical obligation to do so (see Chapter 4), but a review of dento-legal cases suggests that we do not always do this. After undertaking a root cause analysis (see Chapter 3) of over 500 dento-legal cases involving different dentists and a wide range of clinical procedures, we have identified “failure in communication” as the predominant factor in patient complaints and litigation in almost 80% of cases.

The United States National Research Council in 1989 stated in its Improving Risk Communication report that: “Risk communication is successful to the extent that it raises the level of understanding of relevant issues or actions and satisfies those involved that they are adequately informed within the limits of available knowledge.”

Ley, in his book Communicating with Patients, has also identified a number of factors associated with communicating risk to patients. These are summarised in Table 1-4.

We should also not discount the fear factor. This most basic of all human emotions arises from the biological necessity for protection from danger and has a powerful impact on the perception of risk. David Ropeik, a former journalist and lecturer at the Harvard School of Public Health, describes the subtle balance in risk communication between fear, facts and trust, as a seesaw in which trust is the fulcrum and facts and fear balance against each other at opposing ends (Fig 1-2).

We have established (from the work of Covello) that trust and credibility are important in determining the effectiveness of risk communication messages. Our risk communications may be compromised if we fail to instil trust and credibility in the dentist-patient relationship. There are a host of other subfac-tors which may also contribute to the failure in our communications (Fig 1-3).

These factors must not be underestimated; mistrust is the catalyst in conflict and litigation.

In communicating risk to our patients, the message, messenger and medium should be considered for maximum effect. The message should be:

• timely

• clear and concise

• sensitive to patient values and fears

• illustrated with metaphors

• lead to explicit conclusions.

The messenger should:

• be perceived as an expert

• be objective

• admit uncertainty

• respond to emotions

• be charismatic.

Research findings over the past decade show that patients who want to receive written information about clinical interventions tend to be more satisfied with communication after they are provided with this. A combination of formats (e.g., qualitative, quantitative, and graphic) will best accommodate the widely varying needs, preferences, and the understanding abilities of patients. Such communication will help the dentist to accomplish the fundamental duty of teaching the patient the information necessary to make an informed and appropriate decision.

Traditionally, dentists have created their own fact-sheets for use in their practices, with manufacturers of materials and equipment plugging the gaps. Today, information and communication technology have transformed the way we communicate with patients.

Some dentists produce information sheets that require a signature affirming that the patient has read and understood the content, thereby taking advantage of the protection that such literature might offer them against postoperative complaints. Whilst this is considered good practice, it should be remembered that there is more to communication than giving information – feedback and confirmation of understanding are equally important.

In a 1995 editorial in the British Medical Journal, Meredith et al. noted: “Some surgeons have produced fact-sheets that require a signature affirming that the patient has read and understood the content, so taking advantage of the protective veneer that such literature might offer them against postoperative complaints about side-effects. This increases suspicions that they may be using such literature to excuse them further from their responsibilities to communicate with their patients.”

It is necessary to guard against expensively produced, glossy literature that is little more than covert advertising for a particular product or an associated treatment regimen. Information given in support of oral communication must not be used to shield doctors from their patients. It should draw on the extensive efforts already made to improve the provision of information to patients and be developed independently of commercial interests.

This is sound advice on an issue that is sometimes overlooked in general dental practice when supporting literature is also used for marketing purposes.

The barriers to risk communication can be summarised as: