Physicians know the drill for every medical procedure they perform. Yet when a doctor receives a patient who just underwent a procedure with another doctor, going about the usual drill may not be the best idea. The doctor needs to know what their colleague did and incorporate this in whatever they plan to do. Thus, a well-established system of passing on information not only ensures smooth treatment, it also prevents calamity. But, as I unfortunately discovered, such a system does not always exist.

Coming to the Delightful Dental Treatment office is not my favorite thing. So, to save a trip, I ventured for a double feature: a crown preparation and a root canal - both on the same tooth - in one sitting. Dr. M., the crown preparation expert, numbed me, Laura, the nurse, holding my hand the while. I make a point of undergoing dental treatment with my eyes shut, focusing on my breaths rather than on the instruments, so I think he gave me two shots, one in the cheek, another in my upper pallet ("this one will pinch a little," he said and he sure did not lie).

Fifty minutes later Dr. M. announced that he was done and going to get an ice cream. The DDT is a corridor-shaped office, several open spaces in a row, so Laura took me to the next open space and handed over to Dr. J., champion of the root canal.

"I'm going to numb you," says Dr. J.

Wait a minute. This sounded familiar. This is what the doctor told me last week, after I had already been numbed.

"I've been numbed," I mumbled through my miserable jaws.

"Dr. M. only injected your cheek. I'm going to give you another shot," Dr. J. says confidently. He is very authoritative, with his glasses and beard, and I'm starting to get confused. Worse, I cannot trust my own judgment anymore. I'm in some pain, and dreading the first root canal I ever had. It seems like I got an injection other than in my cheek, but what do I know. I wasn't looking. And is the inside of my jaw really called the pallet? These thoughts are swimming through my brain as Dr. J. is preparing the needle.

"I did the inside of her mouth," Dr. M.'s voice rings from across the open space like a Schubert Lied in my ears. Schubert composed Psalm 23, referred to in German as "Gott ist meine Hirt", and I am a believer. It must have been divine intervention that Dr. M.'s next patient came in early, so he never left for that ice cream.

Dr. J. puts down the needle, and my tender flesh is spared an unnecessary injection.

Yet, are we supposed to count on divine intervention in such cases? What Dr. M. wasn't there? Or what if this wasn't an open space office, where you overhear every word? What if Dr. J. and I had not had the "I've been numbed" conversation [this is a huge ‘what if', which I will elaborate on in a future posting] and Dr. J. would not have chimed in?

Information flows at the DDT office. They gave each doctor my X-rays and the health forms I had filled in when first admitted. So how come there was no systematic way of recording the location and amount of anesthesia I received? Important as it is to have a system for when everything works, it is even more important to have a system that captures the extraordinary, the unexpected. That flashes a red signal when pursuing the good old drill is not good enough.

This was not the first time a medical error occurred or nearly occurred at a medical facility. Researchers Donchin, Gopher and their colleagues asked nurses and physicians to record error at an intensive care unit. An average of 1.7 errors occurred per patient, a day. And for a particular ICU as a whole, a severe or potentially detrimental error occurred on average twice a day. Twice a day! Many of these errors resulted from problems of communication between the physicians and nurses. The researchers did not stop at pointing out the problem. The solutions they offer have to do with human engineering - making it smooth, even obvious, to communicate. Low-tech routines, such as making sure that the decimal point is clearly marked on prescription sheets, so the doctor prescribes accurately and the nurse understands what the doctor prescribed, go a long way to prevent errors, without adding complexity to the process.

And here's my two cents for human engineering. Dental patients wear a bib around their neck. How about if the DDT office purchased a Sharpie, and had each doctor write down how many injections he/she gave the patient, and their exact location. Better still, how about if this was pre-marked on the bib? Because I cannot be the only patient ever to have been treated by two dentists in a row. Many similar steps that can be taken, generating a system where none exists. This is how the Federal Aviation Administration strives to prevent accidents - by formulating a routine that covers every possible scenario. Because, as humans, we cannot help but go about our usual ways, and these ways had better keep us safe.

About the Author

Talya Miron-Shatz, Ph.D.

Talya Miron-Shatz, Ph.D., is CEO of CureMyWay, and Associate Professor, founder of the Center for Medical Decision Making, Ono Academic College

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