The risks of taking your eye off the ball

It has been suggested that 'familiarity breeds contempt' and this is as true of the dental setting as of any other situation. The phenomenon can manifest itself in many different ways, of course, but the one thing that they have in common is the capacity to generate a real sense of shock in the clinical setting.

The risk of routine procedures

One of the most obvious situations where one can be drawn into a misplaced sense of security arises when undertaking a procedure which is considered to be routine. The fact that we regularly carry out the same procedures, in pretty much the same way, is actually helpful in one sense because we become familiar with what is involved and compfamiletent in each stage of the process. Our experience helps us to fine-tune the skills we use and our efficiency in using them. But the danger is that we may start to concentrate less, or even miss out a stage in the process because our familiarity with it leads us to believe that we have actually done something, when in fact we have not. In fact our mind is interposing a memory of a previous occasion when we carried out the task, perhaps on the preceding patient. In effect, we have been temporarily confused.

In the field of aviation, a pilot may have flown the same type of plane, on the same route, many hundreds of times. But s/he will still go through the same pre-flight checklist, meticulously and painstakingly checking and cross-checking each item in order to overcome the risks that can sometimes be associated with familiarity.

There is an interesting duality here; in order to ensure that tasks do not become so 'routine' that they slip down the cracks in a human process, we need to introduce additional stages into the process and carry them out routinely and consistently. Another useful risk management tip is to make someone specifically responsible for these important stages in a process; link a name to each area of responsibility.

Longstanding patients

It is not unusual to find that the process of gathering and documenting information on a patient who you are seeing for the first time, is much more comprehensive on that first occasion than it will ever be again.

As we get to know patients, we may not feel the need to go back over 'old ground' or perhaps to risk irritating the patient by repeatedly asking them the same set of questions. We may even believe that we do not need to, because we already know the answer to them.

Yet a change in the patient's medical history may have occurred in the intervening period, perhaps accompanied by new or different medication that could impact upon the patient's oral health, or their dental care and treatment.

Alternatively, the patient's occupation may have changed. In most cases this will have little or no impact upon their dental care - but in others it could prove crucially important if a risk of a particular procedure might impact upon the patient's continued ability to carry out their occupation. If the clinician is not aware of the patient's current occupation, the consent discussions may end up being critically deficient in one or more material respects.

Another potential problem of seeing the same patient over long periods of time - which is the norm for most general dental practitioners - is the risk that we will just stop noticing things that might have attracted our attention had we seen them in a new patient. This risk is the greatest where gradually progressing conditions are concerned. 

It is not unusual, for example, for a dentist to retire after treating a large group of patients over many years, only to be replaced by a new clinician who is quickly overwhelmed by a mountain of historic under-treatment. Encountering a single patient with untreated periodontal disease, caries and multiple defective restorations is quite enough of a challenge, without finding yourself faced with this situation in patient after patient, week after week, after joining or acquiring a practice.

The problem in these situations may be that the outgoing clinician slipped progressively into a way or practising dentistry that failed to recognise and address the patient's real needs, and gradually became oblivious to how far from accepted clinical practice they were slipping. The risk is greater where clinicians fail to keep up-to-date and/or become isolated from their colleagues and current thinking in dentistry; this may be more likely in single-handed practice.

A false sense of security

We can sometimes get caught out because a patient does not behave or react in the way we expect them to. We think we know them, and we say or do something that provokes an unexpected response. This may be because we don't know them as well as we thought we did, or because there is a particular reason why the patient behaves or reacts differently on a specific occasion. The patient who is under stress or who is emotional for a reason of which the clinician is unaware, would be a good example of this. As soon as it becomes apparent that we are getting a different reaction from the one we expected, we need to have the skills to adjust our own behaviour quickly and appropriately. This is one aspect of what is called 'emotional intelligence'. 

Another example of a situation where we need to be able to think on our feet, is when we are in the middle of what we had expected to be a predictable, routine procedure and we encounter an unforeseen complication. It is often the case that when we reflect upon what happened and why, we are forced to accept that we had failed to pay sufficient attention to detail in our preoperative assessment, and as a result we satisfied ourselves (prematurely, and wrongly) that we were embarking upon a 'routine' procedure because we had carried out many similar procedures in the past both successfully and uneventfully.

There is a saying that 'the unexpected doesn't happen very often, but when it happens it is usually unexpected'. The challenge we face is that we actually want to believe that the procedure will be as smooth and uneventful as on all the other occasions when we have carried it out. Our past successes provide us with a false sense of security. Consequently, these procedures carry a particular need for us to keep our eye firmly on the ball, so that we can see what we need to see, rather than what we want to see.

A good example of this is the interpretation of a radiograph which has been taken for a particular purpose in advance of a particular procedure. Here, the risk is that we will be so focused on the procedure that we completely overlook something else on the same radiograph, which could and should have been identified and acted upon.

Think again

The more experienced we become as clinicians, the more confident we become about what works and what doesn't, what is significant and what is not.

A patient is halfway through describing a particular set of symptoms and we are already well on the way to a diagnosis and our preferred treatment plan. We diagnose a familiar condition and implement a standard treatment approach, confidently assuming that the usual outcome will follow. Until the moment when it doesn't, and we need to look closer.
And when we do, we realise that the patient's problem was not quite as simple as it first appeared and perhaps we were a little too quick to jump to conclusions. Here again, familiarity can deceive us.

Treating friends and family

A particular risk arises when treating friends and family members because we can sometimes lose sight of the dual relationship we have with them. On the one hand we have a personal relationship with them, and on the other hand we have our professional relationship as their dentist.

When providing dental care and treatment for friends and family we are still doing so in a professional capacity so all the rules and standards that apply to all other patients, must apply equally to these patients. We must go through exactly the same procedures, and never be tempted to 'fast-track' or 'shortcut' any of them.

This can lead to some potentially awkward moments when taking medical histories from people we have only ever known in a social setting, but if we remind ourselves that we are wearing our professional 'hat', and that the patient in question has chosen to seek our professional services (whether or not we are charging for them), it can help us to stay focused and on track.

Standards of record keeping are often found to be much lower when treating friends and family and sometimes the records are non-existent. Complaints and litigation from friends and family may be extremely rare, but when they occur there is often a breakdown in the previous relationship and feelings can run high. Dental Protection has seen many negligence claims arising as part of divorce proceedings, and patients can become very angry and determined when problems come to light from treatment that was previously provided by a dentist who is also a friend. The patient's feelings of having being 'let down' by someone they knew and trusted, can fuel strong emotions.

Assumptions: The people we work with, the materials, instruments and equipment we use and the dental laboratories with whom we work, and professional colleagues to whom we refer patients or who refer patients to us, are all part of our clinical routine and 'comfort zone'. But over time this familiarity can create risks of its own because we might assume that other people are doing things when in fact they are not, or that certain aspects of a process will take place in a particular way when in fact they won't.

Assumptions are as dangerous in clinical dentistry as they are in aviation and other fields, and we need to guard against them and the risks that they can create.Examples might include the safety features on certain types of equipment, or an automatic timer on an x-ray machine, curing light or other device. In these and other instances there is no room for assumption - for example:

• Assuming that someone else is following agreed procedures in the area of decontamination and infection control.
• Assuming that a dental nurse is adequately protected against Hepatitis B, having appropriately sero-converted following immunisation.
• Assuming that a sedated patient is accompanied by a responsible adult who fully understands their role and responsibilities.
• Assuming that a new dental nurse if familiar with how to mix a particular dental material or to use a particular piece of dental equipment safely and effectively.
• Assuming that someone else has explained the nature and purpose, risks, limitation and benefits of a procedure as part of the consent process.
• Assuming that someone else will take responsibility for keeping an adequate and appropriate record of some aspect of a patient's care and treatment.
• Assuming that a particular piece of equipment (such as a washer-disinfector, or autoclave or eye protection) is doing the job for which it is designed. Are we, for example, regularly auditing the consistency and effectiveness of these procedures?
• Assuming that someone else is ensuring that equipment is regularly serviced and maintained, and operating properly.
• Assuming that patients are actually taking medication that has been prescribed for them.

It will be seen from this list of examples that we might take many things for granted in our professional lives. Nine times out of ten, our complacency does not lead to an adverse outcome, but it's essential that assumptions are not made to reduce risk.  

A sensible balance

Risk is all around us, but this is no justification for us becoming fearful and risk averse. We should instead try to understand and manage risks and accept that we will never eliminate all of the risks, all of the time.

The very fact that we recognise the potential risks of familiarity and repetition of routines, helps to increase our level of alertness. If as a result of that we implement some changes in our every day procedures to refresh and sharpen our approach to them, then we will have made our working environment safer with relatively little effort.

Summary

Risk management is much more about regularly doing little things well, than about big, complicated processes. Implementing small changes and securing continuous, progressive improvement by increments, is also much easier, more accessible and achievable than many people believe.