Failure to obtain medical consultation and improper medication advice leads to seven-figure settlement

Dental Expressions®--From the CNA Claim Files
Medication, Medical Consultation and Related Medical Complication

An accurate, thorough, and current medical history represents an essential tool in providing quality dental care. It also protects both the patient and you from unnecessary risks. Failure to obtain, update, and investigate the patient’s medical history have all been alleged in professional liability claims asserted against dentists. 

Each dental patient is unique, presenting challenges and risks that may lead to adverse outcomes. Providers must understand an individual’s dental history, medical history, current dental/medical conditions, past and current medications, social history and other factors: all may be critical to the delivery of safe and effective oral health care. 

The following claim scenario serves as an important reminder about the need to establish consistent and effective medical consultation processes, ensure that patient instructions and recommendations are clearly communicated, and to maintain accurate and complete clinical treatment records. Treating to the standard of care may also include assessing and applying the latest clinical guidelines and recommendations that apply to the patient’s unique history and circumstances. 

Practitioner: General practitioner

Claimant: 84-year-old female; 15-year history of warfarin anti-coagulant therapy

Risk management topics: Medical consultation; recordkeeping; clinical best practices or guidelines

Facts: 
On the initial appointment, patient indicated that she had a history of pulmonary embolism, hypertension, stroke, cancer, heart murmur, heart attack. She had undergone open heart surgery to place an artificial mitral valve and pacemaker. Patient was taking a number of medications including warfarin. On examination, teeth 4 and 5 had Class II mobility. One year later, the dentist recommended extraction of teeth 4 and 5. He recommended that the patient stop taking all medications, including warfarin, seven days prior to the extraction appointment. The dentist also requested that the patient consult her physician prior to doing so. Eight days later, teeth 4 and 5 were uneventfully extracted with little bleeding. On the day following surgery, the patient suffered a massive cerebrovascular accident and died 6 months later. 

Key allegations: Failure to obtain medical consultation; improper medication advice; failure to request appropriate diagnostic tests, including INR to evaluate coagulation time  

Claimed injury/damages: Massive debilitating stroke, followed by death   

Analysis:

• Accurate documentation.  The chart note to “stop Warfarin 7 days prior” appeared to be a directive to the patient to stop taking the medication.  The dentist stated that this was a question for the patient and that she was to ask her physician about discontinuing the anticoagulant. However, there were no quotation marks (if a patient question) and no question-mark (if a question from the patient to the dentist, or vice versa.) 
• Medical consultation.  Dentists should not rely upon a patient’s communication to the medical professional. The dentist should directly contact other practitioners about proposed treatment, pertinent medical history and appropriate related medical advice.  
• Clinical best practices or guidelines. A hematologist and two general dentists were deposed as expert witnesses.   The hematologist stated that the risk of clot development and stroke for this patient far outweighed any risk of bleeding for uncomplicated tooth extractions.  He estimated that the cessation of warfarin increased the patient’s risk of stroke by 10 times.  He described the patient’s stroke as “massive,” affecting the middle cerebral artery, one of the main arteries to the brain.  Death within one year of such an event is not uncommon. The dentists opined that for most patients, anticoagulant medication should continue during dental procedures, due to the risk of thromboembolism and related morbidity. 
• Proximal cause. There was an apparent causal relationship between the discontinuation of the warfarin and the patient’s stroke, as the stroke occurred one day after the dental procedure. 
• Damages. Although elderly, the patient was self-sufficient prior to the stroke.  At deposition, the patient’s daughter effectively described her mother as vital and active prior to the incident—in contrast to the last six months of her life—languishing, and unable to speak or move.   

Outcome: Defense experts recommended against going to trial: settlement and expenses totaled over seven figures. 

According to the American Dental Association* and other sources, the latest information available supports the statements made by dental experts in this claim. Again, each patient is unique: there certainly may be situations in which it will be in the patient’s best interest to alter their medication regimen. It is critical however to assess the relative risk and severity of potential outcomes associated with such recommendations. Failure to ensure direct consultation with a patient’s physician, medical specialist, or other medical provider responsible the patient’s medical care and medication management may result is serious consequences for the patient and the dentist. 

Article by: Ronald Zentz, RPh, DDS, FAGD, CPHRM, CNA Dental Risk Control 

RESOURCE
*American Dental Association Oral Health Topics: “Anticoagulant and Antiplatelet Medications and Dental Procedures” at https://www.ada.org/en/member-center/oral-health-topics/oral-anticoagulant-and-antiplatelet-medications-and-dental-procedures