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Who are You Treating? Verify Dental Patient Information to Reduce Risk of Wrong Treatment

Performing dental treatment on one patient that was intended for another can yield calamitous results. Define and document the ways your whole office team verifies patient information. 

If your first name is an uncommon one, you’ve likely had it misspelled on your to-go coffee cup by countless baristas. However, if your name is common, you’re more likely to have been handed a cup intended for someone else. While James and Jennifer were once the most popular monikers, the names Sophia, JacksonEmma and Aiden are now shared by young customers in many cafés. Getting a latté meant for another customer may not be a serious issue, but getting dental treatment intended for someone else can yield calamitous results. 

A case study in mistaken identity 

The Dentists Insurance Company’s Risk Management Advice Line recently received a call from a practice that was dealing with a case of mistaken identity for same-name patients. The caller represented two practices: a pediatric dentistry office and an orthodontic office which were managed separately but shared a common patient waiting area. Two patients named Haley were scheduled for treatment at the same time — one in each office. Haley X. (the orthodontic patient) checked in and, in error, an assistant took her into the operatory. Haley X. was not a patient of record at the pediatric side of the office at all, and Haley N., the scheduled pediatric patient, was still in the reception area.

The clinical mix-up continued because Haley N. was scheduled for fillings on teeth no. 2, 4 and 18, and Haley X. appeared to need small fillings on teeth no 2, 15 and 18. So, it appeared to the doctor that a minor charting error had been made — not that the wrong patient was in the chair. To make matters more confusing, the orthodontic assistant did come by to ask during treatment if Haley N. was seated in the operatory at which time the chairside assistant confirmed yes. It was uncertain why the patient did not correct or if she simply misheard the question.

It was not until 30 minutes later when Haley N. inquired as to why it was taking so long to be seen that the practice finally realized their mistake. They advised Haley X.’s mother of the error. She was appalled and left the practice in distress. Shortly thereafter, the mother called the practice and asked that they contact her daughter’s current dentist to review the errant assessment and treatment. The practice where Haley X. was a patient of record confirmed that she did not need any fillings yet, as the teeth were not fully erupted, and the decay was very shallow. 

By the time the Risk Management Advice Line was called, the situation was already a stressful one for all parties. The analyst advised the caller to carefully review the practice’s protocols for checking patients in, including confirming information at the front and back office and comparing X-rays, charts and treatment plans against the schedule. The analyst also encouraged the dentist to call back with further developments, which he did when Haley X.’s mother requested records from the practice where the incident occurred. The analyst urged the dentist to comply with the request for a copy of the treatment notes. Not releasing the information or altering the information would only escalate the situation and the practice’s culpability. 

Another case study in mistaken identity 

In another call to the Risk Management Advice Line, a dentist shared a concern about a clinic set up in a school as part of a grant program. The clinic saw about 1,200 students per year, with parents able to opt children out of screenings and any further treatment requiring parental consent. The caller relayed an incident in which a volunteer went to retrieve a student for treatment from room R3, but he went to room 3 instead. The volunteer asked for the student by first name only and, coincidentally, rooms R3 and 3 had students with the same first name. The full name was not checked, and treatment was performed.

In this case, the dentist had a sit-down with the patient’s parents, principal and clinic supervisor, at which time the child’s mother then claimed her son was traumatized by the incident. The dentist asserted that the performed treatment was, in fact, correct and needed. The mother then demanded a letter outlining the treatment so she could visit another dentist to review it. Again, a risk management analyst advised the dentist to revisit processes and protocols and comply with records request. 

How do treatment mistakes happen? 

While there are a variety of factors that can contribute to mix-ups, research by TDIC’s analysts reveals the most commonly occurring elements. Being aware of these factors can help your practice team develop a proactive approach for prevention. 

  • Errors on referral slips. The most common cause for treatment mistakes is writing the wrong tooth number on referral slips. Allowing staff to fill out the referral forms without getting the treating dentist’s confirmation of accuracy and signature is typically what leads to misinformation. 
  • Performance or production pressure. Often, a dentist who is in a rush trusts their dental assistant to display the correct radiographs and treatment plan for the patient they are treating, failing to verify that the diagnostic displays are the most current or correctly matched to the patient. Scheduling adequate treatment time for cases, paying attention to detail and observing a timeout before treatment can eliminate the temptation to take shortcuts.
  • Staffing shortages. Frequently, performance and production pressures can be blamed on an undertrained or understaffed practice team. Having qualified, reliable staff makes a substantial difference to how the office runs and the level of patient care a practice can provide. Without a well-staffed office able to follow patient care protocols, things can – and will – slip through the cracks.

What can you do to reduce your risks? 

Ensure you treat the right patient with the right procedure by following guidance from TDIC’s Risk Management analysts: 

  • Emphasize the practice team’s responsibility to check patients’ identity and match them with the correct care before any treatment is administered. Incorporate verifying identity into the practice’s training procedures. 
  • Define and document the ways your office verifies patient information. Ideally, use at least two identifiers (e.g., name and date of birth). Consider taking patient photos for identification purposes and including them in the charts. 
  • Review the daily schedule during morning huddle and cross-reference charts and treatment plans against the schedule when the patient is taken into the treatment room. 
  • In addition to verifying treatment plans against the schedule, ensure that radiographs belong to the patient and match the treatment plan. 
  • If the patient is a minor, review the treatment plan and an informed consent discussion with the parent or guardian. 
  • Allow the patient and/or patient’s parent the opportunity to ask questions to understand what to expect at each appointment. 
  • Follow the Joint Commission’s requirement to implement a timeout before any invasive or irreversible treatment to ensure the correct patient receives the intended treatment at the proper site. The timeout is conducted in a fail-safe mode, meaning that the procedure is not initiated until all questions or concerns have been resolved. 
  • Review all referral slips for accuracy before signing and presenting to the patient. 

Review your practice’s protocols and gain the entire team’s commitment to verify patient identity. A few essential steps can protect your patients and your practice from costly mix-ups.

TDIC’s Risk Management Advice Line is a benefit to TDIC policyholders. To schedule a consultation with an experienced risk management analyst, visit or call 1.877.269.8844. 

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