An innocent enough question but, when an adverse incident occurs, make sure the patient’s welfare is your main priority.
A dental patient attended for a routine examination. All was going well until he was asked if he would like to rinse his mouth. After doing so, the patient commented how strange the mouthwash tasted and was offered water to rinse away the taste. Treatment was completed and the patient left the surgery.
After having had time to consider the patient’s reaction, the dental assistant told the dentist that she realised that she had offered a cup of spittoon cleaning fluid to the patient instead of normal mouthwash, by mistake! The patient had by now left the building.
The dentist called Dental Protection who advised him to contact the patient and explain what had occurred. The patient was referred to a local hospital with a letter listing the ingredients of the spittoon cleaner.
Luckily the patient did not suffer any ill effects and did not complain. While dental practices have protocols to prevent accidental reuse of cups or dental equipment in line with good cross infection practice, sometimes bizarre incidents such as this occur because nobody thinks of the possibility of it occurring! While we do not know whether the actual ingredients of the spittoon cleaner were corrosive or poisonous, this in a way is not relevant – it is not for us to decide. It is for us to respond swiftly and appropriately and seek expert assistance.
Fortunately in this case there existed in the practice a culture that encouraged the dental assistant to accept responsibility for her mistake and to put the patient’s wellbeing ahead of any embarrassment or perceived disciplinary consequences for her. This is not always the case in dental practices, but a culture of openness and shared responsibility is likely to lead to better incident outcomes in the long term, no matter the nature of the incident.
Secondly the dentist acted appropriately in seeking advice on the best course of action and also in putting the patient’s best interests ahead of any fear of repercussions. In this case as with most incidents that Dental Protection manages, the consequences of NOT acting responsibly and quickly usually results in worse outcomes for the patient; and should a complaint to AHPRA be forthcoming or a legal claim initiated, worse outcomes for the dentist in not fulfilling a duty of care. Most people accept that mistakes can occur if told about them, but most people are less forgiving if they feel they have been misled or not warned.
In such situations it is very important for the practice to act immediately, log an incident report and after the event for all staff members to discuss how to avoid a similar situation ever arising in the future. While it is unlikely for a patient to ever be offered spittoon cleaner again, protocols can be developed to decrease the risk of any similar situation arising. Again the involvement of all staff members leads to empowerment and shared responsibility.
When an adverse incident occurs in the practice make sure everyone is aware of what has occurred, the patient is informed and appropriate action is immediately taken.
Learning point:
Honesty is the best policy. Contact Dental Protection at the earliest opportunity to obtain support if you need help in managing an unexpected event.
These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits dental members enjoy as part of their subscription.
For more detailed advice on any issues, contact us