Complications: recognising, managing and preventing them

In recent years, dental practice has become increasingly challenging. Patient expectations have never been higher, both in terms of clinical outcomes and service levels.

Meeting patient expectations often requires far more than simply providing work of good quality. Patients nowadays see themselves as consumers and often believe that they are buying a commodity—which, if it doesn’t meet their expectations, means they are entitled to a refund.
They take for granted things like building a rapport, trust, anxiety management and pain control – elements that can, in fact, be the most difficult of all to manage, and for which there is no fee. Recognising that complications will occur is a crucial part of being in practice these days. You may have excellent clinical skills but will need other skills if you are to be able to deal with challenging patients and tricky situations, and sort them out effectively and efficiently.

Recognising risky situations
Distractions are a key cause of misunderstandings and mistakes. These might start off as small errors and later lead to much more serious complications. Every day we have to manage external distractions — phone calls, broken equipment, new staff members — but more insidious and dangerous are the internal distractions, the ones that cause us to respond emotionally.
These are the things that keep us awake at night – death, disease, debt, divorce, depression, drink/drug addictions. If these things are going on in our lives, we will struggle to focus and concentrate fully during the day and become vulnerable to slips, lapses and errors. When under these pressures, we will also be less tolerant of our patients and staff and they may affect our ability to respond to difficult situations in a calm, thoughtful and measured way. Of course, these things may also be going on in your patients’ lives, and if so, they too are likely to be less resilient, more impatient and anxious, and more likely to complain if the treatment or service doesn’t meet their expectations.
Communication skills are vital in trying to build a relationship of rapport and trust early on. A 2017 study carried out by the Medical Protection Society showed that patients place a very high value on communication skills, and are less likely to complain if they feel an effort has been made to communicate with them. We know from 30 years of research that poor communication leads to dissatisfaction for patients and is one of the main drivers behind patient complaints.
Clinical skills are extremely important but if you want to experience high levels of satisfaction among your patients, you need to be able to communicate with each one effectively. This is important when things are going well — but even more so when complications arise. Tailoring your communication style to match each patient’s needs requires time and effort, but it is time extremely well spent. Consider it an investment in the success of the treatment plan going forwards. Should a complication arise, it is likely you will be better able to navigate and negotiate this with the patient if you have already built a solid foundation of good communication.

After the complication occurs
When a complication or adverse incident arises, it is crucial that you respond appropriately and proactively. It is important to explain to the patient what has occurred, apologise for any inconvenience or discomfort, and make sure that they are kept comfortable and safe. Pain management in the aftermath of an adverse event is critical and is often an element of the allegations made at a later stage, as is the need to be referred to an appropriate specialist at the earliest opportunity. You should make sure that you make a detailed record of everything that occurred, paying particular attention to any discussions that were had with the patient. Remember that these records might not be looked at until three/four years later, or sometimes even 10, and may be vital in establishing your defence. Make sure not to abandon the patient. If something untoward has occurred, keeping in touch to ensure they are being looked after and are comfortable is very important. Finally seeking independent objective advice and support as soon as possible can often make the difference between resolving the matter early on or allowing it to fester and escalate.
Every practice must have a complaints protocol. This is a Dental Council ethical and professional obligation. This should be provided to the patient as soon as they raise a complaint. Having a member of staff who is trained in handling complaints is essential. Your patient needs an early acknowledgment of the issue they have raised, usually within three days – and then a commitment to provide them with a full response once you have had time to review the matter carefully. Please make sure to give yourself plenty of time in your protocol to do this, and err on the side of three to four weeks. You can always respond more quickly but it is very awkward to have to keep asking for more time. Our team at Dental Protection are experienced in writing explanation and apology letters and we are more than happy to assist you with this. Having an independent, objective view often makes the response a little more balanced and palatable to a frustrated patient, and facilitates an earlier resolution acceptable to both sides.

Preventing complications
In his book Blink, Malcolm Gladwell discusses what he calls ‘thin slicing’– essentially where patients make judgements based on small amounts of crucial information that they deem to be very important. Research shows that for patients, tone of voice and an ability to listen are extremely important, and that clinicians who are perceived to be good at these things receive less complaints and claims than those who are not.
So paying attention to these two key aspects in the early stages of building a relationship and making the treatment plan, as well as when dealing with a challenging situation or adverse event, is likely to serve great dividends. Managing complex people in challenging circumstances is what we do all day long.
It is inevitable that at times wires may become crossed, mistakes will happen, and complications will occur. Being aware of times when these things are more likely to happen, and also recognising that there are key skills you can utilise to respond to tricky situations, can often make the difference between early effective resolution and stressful, protracted disagreements.
If in any doubt, don’t hesitate to contact your dental defence organisation. Dental Protection members benefit from ongoing learning and development opportunities, including CPD workshops offered periodically throughout the year, to help you avoid claims or complaints.

Nuala Carney
Dentolegal Consultant at Dental Protection