K, now in her late 50s, has been a dental patient of Dr. B’s since K was a teen and Dr. B was fairly new in practice. K had an essentially benign medical history, with one important exception: a history of having had a severe, life-threatening allergic reaction to Penicillin as a child. Dr. B was well aware of the allergy, with K’s patient chart being clearly marked to reflect it.
Dr. B viewed himself as being in his last few years of practice, so he no longer accepted new patients but maintained his existing patients who had been loyal to him for so long. When Dr. B was asked (socially) what his biggest weaknesses were, he responded without missing a beat—awful handwriting and an aversion to technology (the latter of which led to his hanging on to handwritten records and handwritten prescriptions, for as long as the upcoming mandates for electronic prescribing would allow).
Over her last few dental examinations, K had shown a worsening overall periodontal condition, most prevalent in her 2 upper left molars, which had apices in very close proximity to the low-lying maxillary sinus. Tooth #14 was becoming symptomatic, beginning to show signs of an endo-perio lesion. At her most recent office presentation, #14 had several probe points nearing 8mm, with noticeable mobility and pressure tenderness, and slight sinus opacification radiographically. Dr. B advised his patient that extraction looked to be the best solution, at least for #14 currently. With travel plans coming up imminently, K wanted to try to “baby it along” until she returned home, at which time she would have the extraction performed. Dr. B saw no problem with this approach, so he would prescribe an oral antimicrobial rinse and an antibiotic.
As she left the office, Dr. B handed K both handwritten prescriptions, one for the rinse and the other for an antibiotic which Dr. B found to be effective in such situations, Doxycycline, dosed at 100 mg twice daily. On her way to dinner with a friend, K dropped the prescription forms at a busy chain pharmacy near the restaurant, planning to pick up the medications before traveling home. The pharmacist was fairly easily able to discern the rinse and its dose, but the antibiotic was a different story: neither the name of the drug, save for the letters “D” and “x”, nor the dose was readable. The pharmacist called Dr. B’s office, where only the receptionist remained at that time of the evening; the receptionist was able to tell from the chart that K had a periodontal infection, so she passed that information on to the pharmacist but nothing more in terms of the name of the antibiotic. The pharmacist said that he had it figured out, in part based upon the condition being treated: he filled the prescription for Dicloxacillin, which he reasoned must be for 500 mg (rather than what looked to be 100 mg).
K used the rinse that night after brushing her teeth and took the first of the antibiotic pills before going to sleep. She awoke in the early morning hours with shortness of breath and redness on the skin of her chest and torso. She called an ambulance when the situation seemed to quickly worsen and was transported to a local hospital. There, she was diagnosed with an antibiotic-induced allergic reaction which was treated with antihistamines, corticosteroids, and a short period of time being intubated. Fortunately, K was discharged within a few days, and remained out of work for the rest of the week, but the fear put her into a tailspin. She had not understood what caused the allergy until she closely read the antibiotic label and did an internet search, which revealed that she had been given a Penicillin-type antibiotic, Dicloxacillin. Despite her long professional relationship with Dr. B, she was extremely angry with him and immediately wanted to sue him.
Based upon a referral, she found an attorney to review her records and advise her of her options. With the input of an expert, the attorney told K that the fault began with Dr. B’s poor handwriting, that the pharmacist should not have filled the antibiotic prescription with the incomplete information he had, and that the office receptionist gave the pharmacist information about the patient’s dental condition which should have been transmitted only by a dental professional. The attorney concluded that Dr. B, the pharmacist, and Dr. B’s practice entity (as the employer of the receptionist) were all liable and should all be sued. K agreed and a malpractice lawsuit was begun on her behalf.
The respective reviews undertaken by the defense attorneys assigned, and their retained experts, all reached the same conclusion, which was that this situation could not realistically be defended. Given that K’s related injuries were limited to a portion of the ambulance and hospital costs, a week of missed work, and the “pain and suffering” associated with the physical manifestations of the allergic event and the emotional component as well, the path to case resolution became apparent. With contribution from the malpractice carriers of each of the defendants, the case was resolved by settlement early in the process, without the need for depositions or a trial.
One can speculate as to the legislative intent behind moving to an electronic-based system of prescribing medications, but the facts of this case stand as a likely candidate for that reasoning. Had K’s medications been electronically prescribed, rather than handwritten, it is difficult to foresee a way that the mistake which occurred here would have come to pass; such legislation provides a risk management tool to practitioners who provide medication prescriptions to their patients, whether the practitioners like it or not. But even as the transition in prescribing technique has taken hold, or is close to fully taking effect, there might still be outlying situations where dentists have occasion to handwrite a prescription; to the extent that is the case, the situation described in this case study serves as a clear example of the potentially life-threatening dangers that can be posed when communication – whether written, spoken, texted or emailed – is not fully checked for accuracy and properly transmitted.
This concept is far from limited to medication prescription writing, but instead encompasses so many aspects of dental practice. Every day, dentists send requests for appliances to dental labs; seek blood work for their patients, either through their physicians or directly from blood-drawing facilities; instruct their patients on premedication requirements; and provide pre- and post-procedure instructions. Much of these types of information is routinely transmitted on handwritten papers, over telephones, or by way of face-to-face discussions; the takeaway here is that accurate communication is critical to safe and efficacious patient care, with the failure to adopt precise and consistent interaction techniques causing a weak link in overall patient management. As basic and as non-clinical as this concept might sound, it is a solid practice foundation that cannot be overlooked in its importance. The few extra seconds that it might take a dentist to write legibly could amount to literally saving a life. And that comes in handy as well when jurors are evaluating cases with handwritten records: records that are easily read take away unknowns and send the message that the dentist is not trying to hide a thing.
We address here a concept that is not very frequently discussed in our dental case studies, because it is far less pervasive than with our colleagues practicing medicine. Whereas practitioners of multiple practice areas function together often to provide patient care in medicine, dentistry is a profession in which the actions of individual dentists far less frequently cross over to include the actions of others. That is not to say, by any means, that there is never any such crossover in dentistry, as this case demonstrates, so we raise the idea and explain how multiple practitioner interactions play out in litigation. Without delving into underlying legal definitions, suffice it to say that, based upon individual State rules, the relative actions of multiple practitioners who share liability in causing injury, or even the patient’s own liability in leading to their own injury, may be apportioned by a jury to reflect the monetary portion of each player’s role in the undesired outcome, or it may be agreed upon between the parties and their lawyers in pre-trial settlements. The manner by which cases ultimately resolve is not infrequently dictated by an investigation into and an assessment of the engagements of every person and entity involved.
It is beyond the scope of this study to comment upon standards of care guiding pharmacy practice, here or generally. But it is valuable to consider the actions of Dr. B’s office receptionist, and non-professional office staff overall. Dental office staff members are integral to the successful running of a practice: their roles in scheduling, administrative follow-up, billing, insurance filings, and serving as the faces and voices of the dentists who employ them cannot be overstated; many practice owners would find it hard to conceive of how their practices would begin to function without those members of the staff. However, when their functions step beyond those of administrators and into those of clinical advisors, either at the behest of their dentist employers or not, they place those dentists into positions of potential legal peril, in a variety of ways. It is up to the dentist to determine and make clear what actions non-professional staff members may take and what they must not. In this case, the office receptionist provided what amounted to a clinical assessment – or at least insight – as to why K was given the unreadable antibiotic. Had the receptionist not given what she took from the chart to be the reason for the medication, the pharmacist would not have had the information which led him to have “figured it out” and reach an improper conclusion as to what the medication was; had the receptionist simply refrained from giving any information other than she would have Dr. B return the call, malpractice would have very likely been averted.
Practice entity policies function to protect dentists when the (claimed) improper actions of the practice (meaning all under its employ) create an injurious result. It is an invaluable tool in an overall professional liability protection approach, and one not to be glossed over.
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Note that this case presentation includes circumstances from several different closed cases, in order to demonstrate certain legal and risk management principles, and that identifying facts and personal characteristics were modified to protect identities. The content within is not the original work of MedPro Group but has been published with consent of the author. Nothing contained in this article should be construed as legal, medical, or dental advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.
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