Wrong Medication Causes Allergic Reaction

Transcription

1 FALL 2010 thedentists.com Wrong Medication Causes Allergic Reaction PERSONAL CONCERNS CLOUD PROFESSIONAL JUDGMENT A patient is hospitalized after taking medication dispensed by a dental assistant. A risk management resource published by The Dentists Insurance Company, a California Dental Association company. IN THIS ISSUE Mutual Aid Groups 6 Employee Termination 7 At-Will Employment 7 Susan Padilla began seeing Dr. Cynthia Loy in At the initial visit, Ms. Padilla completed a health history form noting that she had an atrial septal defect. Due to the condition, she required premedication prior to dental treatment. In addition, she noted an allergy to penicillin. In accordance with office policy, Ms. Padilla reviewed, signed and dated her health history form at every visit. In 2004, Ms. Padilla presented for a routine exam. Dr. Loy noted decay on tooth No. 14. She reviewed a radiograph of that tooth and recommended a crown. After a thorough discussion of the risks, benefits and alternative of the crown, Ms. Padilla signed an informed consent form. She accepted the treatment plan and agreed to the finances. Dr. Loy documented the discussion in her chart, and gave the patient a copy of the signed informed consent form. Due to a cancellation in the schedule that day, the office extended her exam appointment to prepare the tooth for a crown. Ms. Padilla had not taken her premedication that day, as the original appointment was only for an exam. To provide the patient with the appropriate antibiotic prophylactic coverage, Dr. Loy instructed the dental assistant to dispense four clindamycin capsules to the patient. The doctor completed the procedure without incident, placed a temporary crown on the tooth, and reviewed postoperative instructions with Ms. Padilla. The office scheduled an appointment in two weeks to deliver the permanent crown. Shortly after Ms. Padilla left the office, Dr. Loy noticed her assistant s note in the chart indicating she gave her amoxicillin instead of the clindamycin as she had instructed. Immediately following her discovery, the doctor called Ms. Padilla to determine whether she Continued on page 2

2 LIFELINE LIABILITY ALLERGIC REACTION Continued from page 1 had taken the antibiotic and, if so, whether she was experiencing a reaction. At that point, Ms. Padilla confirmed she had taken the antibiotic, but was not demonstrating any signs of a reaction. Dr. Loy instructed her to call the office immediately if she experienced any symptoms. The next morning, the treatment coordinator left a message for Ms. Padilla as a follow- up; however, the patient did not return the call. Four days after her treatment, Ms. Padilla noticed a rash on her abdomen. She began self-medicating with over-the-counter Benadryl. Over the next several hours, the rash spread throughout her body causing intense itching. The following morning, Ms. Padilla noticed she was unable to swallow because her tongue was swollen. She went to the emergency room, received treatment for the allergic reaction, and was released hours later. The next day, the patient s condition continued to worsen and she returned to the emergency room. The doctor diagnosed her condition as a delayed reaction to antibiotics and she was admitted to the hospital. Two months later, Dr. Loy received a letter from Ms. Padilla s attorney claiming she negligently dispensed amoxicillin, resulting in an allergic reaction followed by hospitalization. The patient demanded compensation for loss of earnings as well as pain and suffering. Dr. Loy contacted TDIC to report the situation. D U R I N G D I S C O V E R Y The claims representative and an expert consultant reviewed Ms. Padilla s treatment records. The record s review did not reveal any evidence that Dr. Loy or her assistant discussed Ms. Padilla s allergy prior to dispensing premedication. In a conversation with the claims representative, Dr. Loy explained that her daughter had been involved in a serious accident and was undergoing treatment, which made it difficult to fully focus on her patients. Since the accident, Dr. Loy dedicated as much time to her daughter s care as possible. She acknowledges delegating certain duties to staff that she would typically handle herself. Having her dental assistant dispense the medication to Ms. Padilla was one way of expediting the process so she could treat other patients and leave the office sooner to be with her daughter. Dr. Loy did not double check the medication her assistant dispensed, as is her standard office protocol. During her deposition, Ms. Padilla stated that she had discussed her penicillin allergy on numerous occasions with the office and diligently noted it on her health history form. She overheard Dr. Loy asking her dental assistant to dispense clindamycin. Ms. Padilla did not question the assistant, and assumed she would follow Dr. Loy s instructions providing the right medication. She acknowledged receiving a phone call from Dr. Loy that day informing

3 3 her of the error the dental assistant made. However, Dr. Loy did not give her any idea of what to expect nor did she explain how long she might be at-risk for developing a reaction to the medication. A medical doctor retained by the defense said he believed Ms. Padilla should have exhibited signs and symptoms of an allergic reaction within hours after taking the amoxicillin. He thought the patient was exaggerating her symptoms. He stated that while it was a breach of the standard of care to give amoxicillin to a patient with a known allergy to penicillin, Dr. Loy met the standard of care when she immediately informed the patient of the error. At the conclusion of the discovery process, Dr. Loy agreed to settle the case prior to trial. The primary factor for Dr. Loy s decision to settle was her daughters deteriorating health. Additionally, the plaintiff had a strong case due to Dr. Loy deviating from her usual protocols by failing to double check the medication prior to her assistant dispensing it. The case settled for a five-figure amount. L E S S O N S L E A R N E D Dispensing Medications Pharmacy laws and regulations state that dentists must supervise the dispensing of all prescription drugs in the office. Staff can dispense medications under the dentist s direct supervision; however, the dentist should define the level of staff involvement and delegation. Implement a policy under which the staff always consults with the dentist when an allergy is Continued on page 4

4 LIFELINE LIABILITY ALLERGIC REACTION Continued from page 3 noted on a patient chart. This type of check and balance can prevent an adverse drug event. As this case demonstrates, medication errors can result if staff (or dentist) does not discuss noted allergies. If you allow staff to dispense medication to a patient, train staff to review the chart for any listed allergies. In this case, Dr. Loy told her assistant which medication to dispense, but failed to remind her of Ms. Padilla s allergy, nor did the assistant review the chart. It is good practice to ask the patient if he or she has any allergies before dispensing or prescribing medications. When dispensing medications in the office, inform the patient verbally and in writing of possible side effects of the drugs. If you are dispensing medications for patients personal use outside the office, label containers or packages with the following: The dentist s name, address and telephone number The dispensing and expiration date The prescription s serial number The patient s name The medication s trade name (or the generic name), and the manufacturer of the drug The medication s strength per unit doses and the quantity prescribed Directions for use Any cautionary statements required by law With respect to patients privacy issues, consider using very generalized color-coded warning labels in various areas of the chart, such as the front of the chart and the health history form. These labels prompt the dentist and staff to review the chart for allergies, premedication requirements or illnesses. Warning labels ensure critical health information is readily available and not easily overlooked. However, under HIPAA law, the label should not betray a specific condition or disease if placed where a patient or non-health care provider could see it and interpret what any coding or color meant. Maintain a log of dispensed medications and perform regular inventories of medications kept in your office. The records might be subject to inspection by an enforcement authority and should be readily accessible. Health History A health history form assists the dentist in determining whether a patient has an illness, condition or allergy that might affect dental treatment. Having accurate and up-to-date health history information is an important step in preventing an adverse outcome. All patients treated in a dental practice must fill out a health history form. It may be advisable to have bilingual dental staff to assist a patient with the form. When reviewing the health history with the patient, question the patient regarding any areas of concern pertaining to his or her overall health. Note any clarifications on the form. Many patients, especially those who are elderly, may not remember certain medications that they are taking until they are questioned.

5 5 Asking open-ended questions such as, Have you experienced any changes to your health? or Have you been hospitalized since we last saw you? may elicit this information when reviewing the form. In cases where the patient s health is severely compromised, have a conversation with the treating physician before initiating treatment of any kind, including prescribing medication. Consult the physician prior to commencing treatment and document the conversation in the patient s chart. Depending on the situation, you may need to communicate with the patient s physician more than once. To facilitate this process, TDIC developed a sample form, Medical Clearance for Dental Treatment, for dentists to send to a patient s physician. Access this form at thedentists.com under the Recordkeeping link of the Risk Management section. A good way to memorialize the transmission of the form is to send via a fax machine that utilizes an activity report that verifies and prints out submissions. Patients should update their health history form at every visit, and sign and date it. The dentist should initial and date the form after reviewing it with the patient. Both signatures serve as evidence that the information is current, and that you discussed it with the patient. Dentists are responsible for everything that occurs in the practice. It is important that staff is properly trained to review patient charts and alert the dentist of any allergies or previous adverse reactions. Any miscommunication on the dentist or staff s part can lead to serious consequences. In this case, Ms. Padilla indicated on her health history form that she was allergic to penicillin. Dr. Loy s assistant failed to review the chart and made the mistake of dispensing the wrong medication. Had she taken the time to review the health history form, she would have noted the patient s allergy and administered the correct medication. Mutual Aid Group Emergencies that affect your ability to practice are impossible to predict. Dentists should establish a plan of action in the event they or a family member suffers a disability, illness or a situation causing interruption to their practice. Often dentists or spouses are caught unprepared. Being part of mutual aid group and having a mutual aid agreement is one of the best ways a dentist can have a plan of action ready to respond to a personal emergency. Dr. Loy was experiencing personal issues and failed to recognize the impact her situation would have on her patients and the practice. She should have had a plan of action ready for bringing in other dentists to treat her patients so she could focus on her daughter s ongoing care. Contact your local dental society, state association or study group for assistance in establishing a mutual aid group. TDIC has copies of the Practice Interruption and Mutual Aid Guidelines. You can obtain a free copy by contacting TDIC at

6 LIFELINE LIABILITY Benefits of a Mutual Aid Group BEVERLY KODAMA, DDS I have been a part of my mutual aid group since the mid-1980s. Prior to 2009, I had only activated my mutual aid group once. That was in 1989 when I had an emergency appendectomy. During my recovery, mutual aid group dentists voluntarily treated my patients, and my staff was able to continue working without me being there. My life as I knew it changed Friday morning, Dec. 4, 2009, when I had surgery to remove a large pelvic mass. Since then, I have experienced several complications as both direct and indirect results of the original surgery. When a six-week anticipated recovery turned into six months, my mutual aid group came to my rescue. In mid-january, my husband, Will, activated the mutual aid group in anticipation of another surgery scheduled for Feb. 4, A torn rotator cuff continued my disability through May. During February and March, the dentists from the mutual aid group volunteered three days a week and produced quality dentistry. The group was cohesive, and the staff felt very comfortable working with each dentist. Two months of volunteering in addition to working in their own practices was a large contribution made on my behalf. Because of their generosity, my practice continued to thrive, and staff had a place to work. In April, I hired an associate, which allowed the volunteers to return to their previous lives. Having mutual aid group members care for my patients allowed me the time necessary to focus on healing. Competent, compassionate dentists voluntarily treated my patients. My staff enjoyed the diversity of techniques and philosophies and truly learned a great amount from the substitute dentists. Since the beginning, the group has met for professional reasons and simply because we like each other. Spouses are often included in group activities. I can see why this is so important. When Will had to contact the group on my behalf, he already knew the dentists involved and was comfortable talking about a very serious and personal matter. Likewise, the dentists knew Will and were comfortable discussing my office protocol with him. Continued on page 8

7 7? Q & A Q: I am about to terminate an employee for the first time. What is the best way to go about it? A: Handle employee terminations in a confidential and professional manner. Consider having an objective third party, such as an office manager, practice partner or associate present when you terminate the employee. If you have an office manual, follow whatever guidelines are established in the manual. Final pay requirements vary by state. Most states require final pay at the time of termination along with pay out of any earned unused vacation. If you provide health benefits, you may have to supply information on maintaining benefits under the Consolidated Omnibus Budget Reconciliation Act, better known as COBRA. Do not withhold any money related to the employee s refusal to return an office uniform or property. Consistency when terminating employees is vital. If you provide severance or extend health benefits to one person, you may have set precedence for all terminated employees. Contact your state labor board or commissioner to determine when final pay is required and if you must distribute any specific documentation, brochures, or materials to an employee upon termination. Consider providing a short written statement such as, As of (date), (name of employee) is no longer an employee of (practice s name). Enclosed is (his or her) final paycheck in the amount of ($ ). This represents payment for all hours worked and all unused vacation. In some jurisdictions, a terminated employee has a right to copies of anything from his or her employee file that he or she has signed. That is not true in others. Check with legal counsel in your state. Consider changing locks and alarm codes to the practice. Delete the terminated employee s password from your computer and your office alarm systems. Q: What is the difference between at-will and for cause employment status? A: For cause employment means you must provide a valid reason for releasing the employee such as fraud, breach of employment agreement, safety, tardiness, or failure to comply with office protocols. In many cases, this requires a first warning, a period of probation and then a second transgression or violation. At-will employment allows either the employer or employee to terminate the employment relationship without notice at any time and for any reason that is not in violation of applicable state and federal laws, such as discrimination or retaliation. All states, with the exception of Montana, are designated at-will employment states; however, a simple statement such as Keep up the good work and you ll have a job here for life can change that employment relationship from at-will to for cause.

8 The Dentists Insurance Company 1201 K Street, 17th Floor Sacramento, CA PRESORT STANDARD U.S. Postage P A I D Permit No Sacramento, CA For the Risk Management Advice Line or Claims, call For more information about TDIC, call or visit us online at thedentists.com Liability Lifeline is published by: The Dentists Insurance Company 1201 K Street, 17th floor Sacramento, California , The Dentists Insurance Company MUTUAL AID GROUP Continued from page 6 Activation of the group does not have to be limited to an event involving the dentist directly. Situations such as a traumatic injury or illness of a spouse or child, or the death of a spouse or child could be an impetus for some dentists to activate the support of a mutual aid group. When things like that happen, the group can be an incredible source of emotional support in addition to practice support. Being a participant in a mutual aid group allowed me to have a lower disability and overhead insurance premium. Additionally, the mutual aid group allowed my practice to continue producing revenue. The customary waiting period until disability insurance becomes active did not affect my income as much as I suspect it does others who become disabled without the support of a mutual aid group. My practice continued to treat patients and bring in revenue throughout my recovery period. Mutual aid groups work. Unexpected events happen. Mutual aid participation allows the dentist to concentrate on the unexpected without jeopardizing patient care, and provides practice viability and most of all peace of mind. That is priceless. ENDORSED BY: Also selling in: Arizona and North Dakota TDIC reports information from sources considered reliable but cannot guarantee its accuracy. TDIC is a California Dental Association company.