Our latest Healthcare blog reviews the importance of risk management in dentistry and the consequences of poor investigation on patient health.
Oral Cancer and Dentistry
It is a well-known fact that a delayed diagnosis of oral cancer is associated with decreased survival and can significantly impact the chances of curative therapy. The ten-year survival rate is between 19% and 58%, depending on exactly where the cancer is located and how early it is diagnosed1. Although, like skin, the oral cavity provides an easily accessible site for identification of a cancerous lesion, oral cancers often are not diagnosed until the lesion is quite large and has metastasised to the lymph nodes or other regions.
Dental professionals are in an ideal position to spot the visual symptoms of cancer and yet delayed or missed diagnoses are still common. Nearly 85% of claims relating to oral cancer handled by one organisation between 2008 and 2012 involved dental professionals allegedly failing to check the patient for oral cancer during the check-up, failing to diagnose a suspicious lesion or failing to refer to a specialist.2
The aggressive nature of the disease means that missing one opportunity to make an early diagnosis or prompt referral can have serious consequences for the patient’s prognosis. So important is early detection that when the British Dental Association, the Royal College of GPs and Cancer Research UK developed the Oral Cancer Toolkit, they recommended not following the NICE guidance of cross-referral by a GP to a dentist for a second opinion but to refer patients directly for a cancer pathway referral3. Cases of oral cancer have been dramatically rising for both men and women during the last decade and now over 8,000 people a year are newly diagnosed with oral cancer in the UK4. It is the 6th most common cancer in the world,5 and there are national awareness drives to raise its profile however, claims against dentists for missed or delayed diagnosis are not reducing.
Record Keeping and Investigations
While comprehensive records are important for all patients, the only hard evidence to support that the dentist has not breached their duty of care in the case of a missed diagnosis for oral cancer will be within the clinical records. At the very least the records should show details of examination, findings (negative and positive), diagnosis, recognition and referral, and follow-up. Dentists must have a low threshold of suspicion when it comes to any lesion or swelling.
We have seen dental cases in mis- or delayed diagnosis where, on reviewing NICE or best practice guidance in place at the time of the patient’s presenting symptoms, a referral was warranted but did not happen or was not timely enough. The investigations into these incidents are often simply a regurgitation of the medical record with no rationale as to why the clinicians didn’t refer in line with best practice guidance despite often seeing the patient on several occasions for the same, visible symptoms that were noted in the clinical record. These cases reveal that the quality of record keeping of the consultations and subsequent incident investigations are poor and frequently the only recommendations from the investigations are to have further training on oral cancer recognition and referral guidelines
Research has shown that weaker solutions such as reminders and retraining are common for investigators to recommend rather than actions that could address the latent causes such as poorly designed training programmes or defective operational systems.6
Risk Management
The critical first step in enhancing patient safety and reducing exposure is to know the common risks encountered by dentists and to have processes in place to manage them. There needs to be a commitment to risk management education as a means of improving safety, reducing risk and lowering claim and business costs. A study of CNA dental liability claims has shown that the average claim cost for insured dentists who participate in risk management education programmes is approximately 20 percent below the overall average claim cost.7
The link between thorough incident investigation and a reduction in reoccurrence is clear and well documented, and the converse is equally true. Patients and their families deserve more. As do the staff delivering the care and service to them.
1https://www.dentalhealth.org/stateofmouthcancer
2https://www.theddu.com/guidance-and-advice/latest-updates-and-advice/avoiding-misdiagnosis-of-oral-cancer
3https://scienceblog.cancerresearchuk.org/2015/11/27/mouth-cancer-dentists-and-gps-should-be-able-to-refer-patients-straight-for-tests/
4https://www.dentalhealth.org/stateofmouthcancer
5https://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=106
6https://qualitysafety.bmj.com/content/26/5/417
7CNA Dental Professional Liability 2016 Claim Report