Managing risk better
Work with your patients to make choices that are right for them
Many treatments we provide for patients have a risk of complication1. In a busy clinical environment, risk will always exist. By managing risk better, we can work with our patients to make choices that are right for them.
An individual’s relationship with risk is unique to them, shaped by their attitudes, values and beliefs2. When weighing up options about their dental care, people must weigh the advantages and disadvantages, which may vary from person to person depending on what matters to them. Managing risk better requires us to recognise that there are two experts – the dental professional and the person you are providing care for.
Dr Will Harrison, Senior Registrar in Oral Medicine, offers insights on how you can work with your patients to manage risk better through some oral medicine case studies. “Risk is part of everyday life – whether in the clinical or non-clinical setting,” he said.
“In dentistry, taking measured risks can contribute to improving quality of life for patients3. Clinicians can be reticent to consider treatment or management plans that involve risk due to fear of patient harm or legal implications.”
While applicable to all clinical scenarios, this is especially true when managing less prevalent conditions, such as those common to the practice of oral medicine.
Dr Harrison added: “Local access to specialist-level oral medicine care is not universal, owing to small numbers of oral medicine units in Scotland. Clinicians must use resources wisely while factoring in decision making on ongoing review and management, with or without direct specialist contact, when considering treatment options with patients.
“Circumferential care is not always possible and oral medicine professionals routinely work collaboratively with primary and secondary care colleagues to provide appropriate care.”
This decision-making process can be strengthened by engaging in shared decision making with patients. The BRAN tool4 can be used to navigate high-quality discussions, ensuring patients are fully informed and aware of the appropriate and available options to them.
A patient with facial pain
A patient presents with facial pain and is diagnosed as having trigeminal neuralgia. Initial management could include referring them to secondary care and starting the patient on Carbamazepine5. Risks a dentist may consider before doing so include the potential lack of baseline bloodwork, the medication side effects and the possibility of a different diagnosis6.
Risks here can be mitigated by having and documenting meaningful conversations with the patient, giving clear explanations and advice about your working diagnosis, and listening carefully to what is important to the patient. Use of the BRAN model here can help you have high-quality conversations that aid shared decision making.
The dentist can liaise with the patient’s GP to check baseline bloods or for the existence of renal/hepatic issues, and with oral medicine prior to referral for advice and assistance. By referring to appropriate guidance, the dentist can ensure that both they and the patient are familiar with the risks involved.
The dentist can also manage risk better by carrying out safety netting. Safety netting is defined as information shared with a patient or their carer, designed to help them identify the need to seek further medical help if their condition fails to improve, changes, or if they have concerns about their health7.
A patient with an oral lichenoid tissue reaction (OLTR)
You provide care for a patient who is diagnosed with an oral lichenoid tissue reaction (OLTR) in relation to an amalgam restoration which is asymptomatic.
The patient does not wish to have the metal restoration replaced due to the risk of iatrogenic injury and they have no symptoms. They are discharged from oral medicine for ongoing management in primary care, who inform you and the patient of the review periods, safety netting and that either you or the patient can get back in touch if there are concerns.
You discuss this with the patient, advising them of what to look out for and to contact you if they feel the lesion is changing, and the importance of attending for review. Not only does the patient have an outcome they value, they also share in ownership of their health by ensuring they attend for follow-ups with you. This also simultaneously demonstrates an impactful and appropriate use of resources.
To deliver outcomes that matter to people, we need to accept the inherent nature of risk in caring for our patients. We manage risk better by having and documenting conversations and making informed decisions with people. More transparency and more meaningful conversations may lead to less litigation, not more.
References
- Read the full article www.ddujournal.theddu.com ↩︎
- Read mananging risk on NHS Learn learn.nes.nhs.scot ↩︎
- Risk Enablement Toolkit version 3 (NHS Grampian PDF) ↩︎
- Its ok to ask, nhsinform.scot ↩︎
- SDCEP Dental Prescribing ↩︎
- RSC England – Trigemina Neuralgia Guidelines ↩︎
- Safety netting in the consultion, The BMJ ↩︎