Medical Emergencies in the Dental Setting

Inadequate emergency planning and protocols—including staff training, medication storage, and equipment maintenance—can cause negative outcomes. This case study examines the risk management issues involving a dentist and his staff who were unprepared to handle a medical crisis.

A young adult presented to a dentist for wisdom teeth removal. The patient had an intense fear of dentistry and was reluctant to undergo the procedure. Although the patient’s medical history prior to the procedure was insignificant, a complete family medical history was unknown because the patient had been adopted.

An oral benzodiazepine was prescribed, and the patient was instructed to take the medication one hour before arrival. The patient was assessed after arrival and vital signs were found to be stable. The patient was very quiet and soft-spoken when taken to the operating suite, and the dental team assumed that the premedication had achieved the desired result. An IV was inserted without difficulty but before the parenteral sedation was administered, the patient stated, “I feel really strange.”

The patient suddenly became unresponsive and developed respiratory depression and subsequent cardiac arrest. The dentist instructed his staff to call EMS and ordered the practice’s automatic emergency defibrillator (AED) and emergency supply cart.

The emergency supply cart was located in operating suite three, but the patient was in suite one. The hallway between the two suites was blocked by a copy machine, so the cart had to be routed through another area of the office to reach the patient. In addition, the wheels of the cart were locked and efforts to push it forward caused it to fall over and the contents to spill onto the floor. The dental assistant retrieved the items from the floor, placed them on the cart, and finally delivered it to the operating suite.

The dentist requested additional medications after the emergency supply cart arrived. The hygienist retrieved the medications from the cart but noticed that they had expired. The dentist requested an alternate medication, but it was not available in the dental practice. Oxygen was used to resuscitate the patient, but gas in the tank was minimal and became completely depleted prior to the EMS team’s arrival. Although the AED battery had not been inspected for a year, it was still effective.

Resuscitation efforts continued with a combination of the AED and the medications available in the operating suite. EMS transported the patient to the hospital, and cardiac tests concluded a familial polymorphic ventricular tachycardia (FPVT) diagnosis.

The patient was successful in a professional liability claim filed against the dentist.

Risk Management Discussion

Because patients may experience medical emergencies while receiving dental care, it is critical for practices to have systems in place to respond to emergency situations. Medical emergencies that can develop without warning include the following:

• Syncope.
• Altered consciousness.
• Cardiovascular events.
• Allergies.
• Respiratory issues.
• Seizures.
• Diabetes-related symptoms.

Preparedness is essential in ensuring patient safety and preventing catastrophic outcomes.

In this case, although FPVT is rare, it is an example of the type of scenario that can surprise dental staff, especially when a patient appears to be healthy. Although a preoperative assessment of the patient was completed, this case illustrates how an inadequate or unavailable medical history and communication failure can lead to an adverse outcome. In this case, the patient’s verbal concern prior to parenteral sedation was likely an indicator of respiratory depression.

The medical crisis ensued rapidly and without warning. The dental practice had failed to conduct regular inventories of medications and had not performed routine practice drills prior to the event. The absence of these protocols left the dentist and his staff unprepared for medical emergencies.

The following strategies can help dental professionals improve patient safety and mitigate risks:

• Review state laws and regulations regarding emergency preparedness as they apply to your practice.
• Prepare your team to recognize signs of urgent/emergent situations. Ensure that each employee has the appropriate level of training in basic life support and advanced life support as required by state law, in addition to pharmacology training on anxiolytics and sedatives prescribed by the practice.
• Assign all emergency-related tasks—such as retrieving emergency supplies, checking patient vital signs, and calling 911—to individual staff members. Have a backup plan for staff absences.
• Develop written protocols for handling emergencies of all types. Include the protocols in new staff orientation and review them annually with all staff members.
• Perform and document routine checks on emergency medical supplies and medication inventory. The checks should include monitoring expiration dates and battery life as applicable.
• Train staff on the proper use, handling, storage, and replacement of emergency oxygen tanks.
• Conduct preprocedure team briefs with all involved staff to discuss the plan of care, necessary equipment and supplies, team member roles and responsibilities, potential complications, and contingency plans.
• Perform emergency drills and simulation training for various medical and behavioral emergency situations.
• Hold postincident debriefs with staff to identify areas for improvement. Assign responsibility for improvement tasks and follow up to ensure assigned tasks have been completed.
• Educate the entire practice on teamwork principles. See the Agency for Health Research and Quality’s TeamSTEPPS® tools.
• Follow your state laws, dental board requirements, and malpractice carrier’s recommendations regarding reporting and disclosure after an adverse event.

For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.