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Sorry Works! Blog

Making Disclosure A Reality For Healthcare Organizations 

Toddler Dies During Routine Dental Procedure; Mom Wants Answers

daisy 14-month old Daisy Lynn Torres went to the dentist last week to have two cavities filled. Daisy needed to be put under during the procedure, but never woke up. A few weeks hours later she was pronounced dead at a local hospital. Her mother wants answers.

Think about it....this little girl went to the dentist to have two cavities filled and died. It doesn't getting any more routine than filling a cavity, right?

Here is the link for this story. And here's a link for the death of a healthy teenager during a wisdom tooth extraction.

How would you handle these "routine" procedures gone terribly wrong? Could you handle it? What would you say? What would you do? What would you not say??  And how would you to stay connected with the family moving forward?

When I do Grand Rounds presentations, I start with a similar case....a true story about an ordinary test -- CT guided biopsy of the liver -- which turns tragically wrong. A 53-year old woman dies during the procedure, and I ask my audience to role play with me by pretending that I am the widower whose wife just died during this test. Instead of taking my wife home, I will be going to a funeral home that evening to pick out a casket. "What are you going to say to me? What are you going to do for me?" I ask my audiences. Most of the time it's silence. People look at their hands, the floor, their smartphones...anything but my eyes. It's painful yet revealing. "And this is why I am here," I tell my audiences. "Because if you can't handle this hypothetical with a paid speaker, what will you do when this case really happens in your hospital next week or next month?!?"   

We can ask the same question of our dental friends...what will you do when the mundane turns tragic? What would you say to Daisy's mom, or the parents of the dead teenager?

The Little Book of Empathy is a must-read for front-line clinicians...it shows them exactly what to say and how to behave following adverse medical events, and the book can be read in 30 minutes or less. Great tool for front-line staff....order a copy today.

Interestingly, in the article about Daisy's tragic death there is a quote from an Ohio State University dental professor: "Currently, there are no publicly available statistics on how many injuries or deaths result from dental procedures in children, said Dr. Joel Weaver, a dentist anesthesiologist and emeritus professor of the Ohio State University Medical Center. 'Most states require that there be a reporting of any dental office death to the dental boards, but they generally don't share that information,' said Weaver. When there are malpractice suits, settlements often include a gag order that prohibits plaintiffs from talking about it, he said."

A lawsuit followed by a good 'ol gag order.  Not doggin' the Ohio State dental professor...he's just telling the sad truth.  Heaven forbid anyone learn from an adverse medical event! Heck, if clinicians actually learned from tragedies we might put the poor old lawyers out of business, and, well, we can't have that! The article above about the dead teenager had plenty of "no comments" following the settlement of the lawsuit. Let's all be quiet because we don't want anyone to learn. Shhhh!!!

So, when the everyday procedure or test goes wrong, do you know not only what to say in the immediate aftermath of the event, but do you have a disclosure program in place that allows you to hit the finish line? And when I say hitting the finish line I want to see people talking about the case, possibly involving the patient/family in the fixes, and meeting the emotional needs of all sides, clinicians included, as well as addressing financial implications for the patient or family. To design, launch, and sustain a successful disclosure program, be sure to get a copy of the Sorry Works! Tool Kit.

 

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