The Dental Council's guidance 'Professional Behaviour and Dental Ethics' states that a dentist has a duty to provide emergency treatment for their patients outside normal surgery hours and patients must be advised on how to contact the dentist should an emergency arise.
Our medical colleagues working in city or urban areas, rather than more rural settings, usually provide an out-of-hours service on a rota basis and sometimes this is a service supplied by a private company which employs clinicians specifically for this purpose.
There is increasing evidence to show that these arrangements carry a much greater risk medico-legally than the more traditional arrangements whereby a patient sees the person who normally treats them (typically, their regular doctor).
There are many reasons why this might be so, including the following:
- It is clearly an advantage if the treating clinician already knows the patient, their background and their medical history.
- It is similarly an advantage if the patient already knows the clinician and a degree of trust and confidence will in most cases already exist.
- In any emergency situation there may be less time.
- In an out-of-hours emergency situation there may be fewer back-up facilities.
- In an out-of-hours emergency situation, the clinician may be working alongside less experienced and/or unfamiliar team members.
Further potential problems arise if the clinician is also working in unfamiliar surroundings or using equipment that they do not use on a daily basis. An out-of-hours medical consultation may be very different from the equivalent dental situation, but there are still lessons that can be learnt and which have application in the dental setting.
Treat people, not teeth
When patients present as an emergency there is a risk that we will treat the presenting condition, rather than treating the patient as a person. There may be (or seem to be) pressure from the patient to find out what is causing their problem, and to deal with it as quickly as possible.
This can result in shortcutting the usual diagnostic processes - taking a more superficial history than usual, carrying out a more cursory examination (perhaps of a limited area only) and sometimes, forgoing investigations and tests that one might carry out in any other circumstances.
The adage 'never treat a stranger' is worth bearing in mind because the less we know about someone, the greater the potential that we will be caught out by a lack of information. One small detail can make all the difference between successful, uneventful treatment and a significant adverse event.
Time pressures
When time is short, it is the process of building rapport with a patient that is generally sacrificed. Unfortunately, this is the very process that is known to contribute in large measure to a patient's perception of a clinician and the likelihood that they would make a complaint or sue the clinician if things don't go to plan. We dispense with this important preliminary stage at our peril, therefore.
The process of asking questions and listening carefully to the patient's answers lies at the heart of every successful consultation. It helps us to gather important information and to fill in any gaps in the overall picture. It also demonstrates that you are interested, and care for the patient at a human level. Asking 'open' questions (ie. questions that are seeking a more detailed answer than a simple yes or no) will obviously take longer, but it provides detail that a series of 'closed' questions will not uncover (most 'closed' questions invite a short response such as yes or no).
Unfamiliarity
Errors often occur when we depart from a well-rehearsed, familiar way of carrying out a particular task or activity. Working in unfamiliar surroundings or alongside someone with whom you have never worked before, or using different equipment, instruments and materials, invites problems because you have relatively little control over the risks and uncertainties of your working environment. This unfamiliarity is thought to contribute to the high level of medical risks seen in out-of-hours arrangements where clinicians work in centralised clinics rather than in their own practices.
The dentistry itself may be the same, but even relatively simple, routine procedures are made more complicated and less routine, if we are trying to carry them out in an unfamiliar setting.
Chaperonage and back-up
One additional challenge in an out-of-hours emergency situation is that back-up staff may be in short supply, or even non-existent.
Other than in the most exceptional of circumstances, a clinician should always try to have a third party present whenever treating a patient. It is important to provide chaperonage - especially when a male clinician is treating a female patient. For this purpose the third party could be someone accompanying the patient, rather than a second member of the dental team.
In addition a trained and experienced second dental team member should be present, whether or not the patient is accompanied. Firstly, because it is likely to improve the quality of the care and treatment provided, and also make life easier for the dentist and more pleasant for the patient.
Secondly, and more importantly, for reasons of patient safety; in order to assist the dentist in the event of a medical emergency every member of the dental team should be trained in the management of medical emergencies. The role of each team member should be understood and rehearsed in a simulated emergency situation. The presence of a second member of staff who has not received such training is of relatively limited value.
Buying time
Dental emergencies are rarely life threatening, and one option is always to restrict the treatment to that which can be provided safely and to an appropriate standard, within the limitations of the facilities and back-up support available at the time.
Similarly, it is unwise to start any procedure (for example, a surgical extraction) unless one can be confident that it can be completed safely and successfully under the circumstances prevailing at the time. This is a matter of judgement, taking into account the experience of the clinician, and the facilities and support available.
Dental Protection is the leading indemnity provider.
Find out more