RISK Management- Plot out a strategy for all the what ifs

Oct. 1, 1998
Stories of theft, murder, and other crimes dominate the media. Daily, you face decisions about protecting yourself and loved ones from such events. As a result, you may rely on a home security system, cellular phone, or personal pager that allows you to be contacted or to call for help in an emergency.

Linda Harvey, RDH, MS

Stories of theft, murder, and other crimes dominate the media. Daily, you face decisions about protecting yourself and loved ones from such events. As a result, you may rely on a home security system, cellular phone, or personal pager that allows you to be contacted or to call for help in an emergency.

Do dental hygienists face "clinical" risks? How often do you take measures to protect your professional license? In your office, many different circumstances exist that have the potential for risk. The types of risks encountered range from personal and patient safety to contracting or spreading disease, which could result in injury to patients, co-workers, or yourself. The opportunity for clinical risk surrounds you daily.

The following risk-management tips increase the overall safety of your clinical practice and reduce the potential for accidents, injuries, or lawsuits.

What is risk management?

The goal of risk management is to reduce or eliminate the risks inherent in accidents, injuries, or lawsuits. This goal is accomplished through a systematic approach where areas for potential risk are first identified and analyzed. Specific strategies are then selected and implemented. Lastly, the results are monitored and corrections are made as needed.

The risk-management process effectively reduces the potential for risk in a practice. Risk management can be implemented seamlessly and almost effortlessly, especially when combined with good judgment and common sense. Risk management isn`t as hard as you may think.

The opportunity for risk is present in every aspect of your practice. How do you practice safely without paranoia? Risk management provides one stable solution in this ever-changing environment.

The first step is to identify where the potential for risk exists. To do so, examine all the activities you conduct and the patient care you provide daily. Then, develop a detailed list, starting at the beginning of the day and proceeding step-by-step throughout the day. Your list may include:

- Setting up your treatment room.

- Providing patient care.

- Disinfecting the treatment area.

- Cleaning equipment/instruments.

Remember to be specific when listing each step. For example, when providing care, include each procedure even though every patient may not receive all the care or services listed. Include the medical history update, blood pressure, pulse, periodontal probing, intra- or extraoral exam, scaling, root planing, polishing, radiographs, charting, documentation, and so forth. Review the "Risk Identification Chart" above for guidance in listing your activities. Two tasks are already listed to help you begin the process.

The second step is to analyze each task or situation for potential risk. Do so by asking these questions:

- What is risky about this situation or procedure?

- Is there risk if the procedure is omitted or not carried out properly?

- What else could go wrong?

Fill in the second column of the chart as you answer each question.

Suppose your list includes taking medical histories and performing infection control duties. Apply the three questions to both tasks in order to analyze the risk involved.

- Medical history - What is risky about a medical history? Treating patients without adequate knowledge of their current health status jeopardizes the patient`s health and well-being. Not knowing medications the patient is taking, the possible drug interactions or contraindications to dental treatment may result in an adverse outcome. Thus, the potential for risk is great if the medical history is not complete or updated routinely. Is there anything else that could occur? Becoming lax in one area of your practice opens the door for bad habits to develop in other areas as well. Taking a thorough medical history ensures patient safety and represents one aspect of quality care.

- Infection control procedures - What is risky about infection control? Undoubtedly, if certain procedures are omitted or are not carried out properly, injury, infection, or disease may occur. The effects could be widespread and devastating. A definite risk exists if infection control is omitted or not carried out properly. What else could occur? Intentional acts of omission may lead to unintentional or unforeseen consequences. Besides any immediate injury, there is a risk of the unknown. In other words, not knowing exactly if others were exposed or infected until sometime into the future. It is possible that the effect of the exposure will not manifest itself immediately. Therefore, always follow recommended guidelines and stay abreast of current infection control procedures.

Continue this process with each task on your list. It is possible for a task to have more than one potential risk. Again, be as thorough as possible.

Implementing risk management

Once risks are analyzed, proceed to the next two steps - selecting and implementing the risk management strategy best suited for the circumstance. The three strategies most applicable to the practice of dental hygiene are risk avoidance, risk prevention, and risk reduction. Your goal is to avoid or prevent a risk. If all efforts fail, however, strive to reduce the severity of the risk.

When risk avoidance is applicable, the risk is eliminated because the task is not conducted or the situation is avoided. For example, you may choose not to use thinly sharpened curettes because there is a risk that the instrument tip could break subgingivally. So you choose to avoid this situation.

Prevention averts a risk by lessening the likelihood that it will occur. Preventive strategies are proactive in nature. They involve implementing activities, procedures, or policies such as staff training and safety programs that are designed to prevent a loss.

The goal of risk reduction is to lessen the severity of the accident or injury once it occurs. This strategy is reactive in nature and includes activities, procedures, or policies designed to be carried out after an accident or injury has occurred. Risk reduction may include, but is not limited to, emergency preparedness, first aid, or even public relations activities. These strategies may be used individually or collectively to achieve your goal.

When deciding which strategy to use, ask the following questions. Complete the Risk Identification Chart as you answer each question.

- Is it possible to eliminate or avoid the task or situation? Can you eliminate the risk by not performing the task?

- Is it possible to prevent the accident or injury from occurring? What activities can be carried out to prevent an accident or injury?

- What can be done to lessen the consequences once the loss has occurred? When an accident occurs, what activities can be carried out to lessen its severity?

Let`s return to the two examples from above. Risk avoidance would mean not taking a medical history or carrying out infection control procedures. Obviously, it is not possible to avoid either of these vital functions. Instead, let`s decide whether risk prevention, risk reduction, or a combination of both is most appropriate.

Analyze the circumstances in which a change in your behavior or routine may very well prevent an accident or injury. Consider the following prevention strategies for these two examples. Thorough medical history information must be obtained and then updated regularly. One preventive action would be to have patients arrive five to 10 minutes prior to the appointment, allowing time to complete the update form before the actual appointment. This saves precious chair time for reviewing the medical history and not for filling out forms. In the end, using this or a similar strategy may prevent a medical emergency or adverse reaction.

A preventive strategy for infection control may be as simple as choosing the proper glove for each task. For example, to prevent injury, latex examination gloves should not be worn when cleaning instruments or working with glutaraldehyde for extended periods of time. Nitrile or butyl rubber gloves offer the best protection against instrument or needle sticks. In addition, research has shown that latex gloves are the least effective protection against glutaraldehyde permeation. In solutions of 2 percent and 3.4 percent, permeation of latex gloves occurs in 45 minutes. A preventive strategy for this scenario might include having nitrile gloves in each operatory and several pairs in the sterilization area. Doing so increases staff safety and decreases the opportunity for injury.

Finally, if, despite all efforts, an injury or accident occurs, have procedures already identified that serve to reduce its severity. Consider what can be done to lessen the severity of an adverse event due to an error or omission in taking the medical history.

For example, suppose your patient has Type I diabetes. The patient`s diabetes regimen has not been updated. Your appointment runs over time and your patient, now late for lunch, begins to have a hypoglycemic episode. Early recognition of hypoglycemia and immediate assistance on your part (such as having glucose tablets, orange juice, or even sugar packets available) can reduce the severity of the low-blood sugar reaction. In this or similar scenarios, initiating emergency response procedures quickly can reduce the severity of a medical emergency.

Next, consider what happens if a needlestick occurs when recapping a contaminated needle. What can be done to lessen the impact of this type of risk? One risk reduction solution is to follow the OSHA post-exposure procedures for prompt follow-up if a cut or needlestick occurs. These procedures should be found in the OSHA manual that your office is required to have by federal law. Additional sources for OSHA information include the OSHA Web site and your local or regional OSHA office.

Has the risk gone away?

Lastly, monitor the results of your strategies and make corrections accordingly. It is important to know whether or not the desired outcomes were achieved. When monitoring, here are several questions to ask, depending upon the strategy used:

- Has avoiding the task successfully removed the risk?

- Have risk preventive strategies successfully prevented accidents or injuries?

- Have risk reduction strategies successfully reduced the consequences of the risk?

Positive responses indicate the strategy is effective. In that case, continue using the particular strategy and update it as needed. Negative or ambiguous answers indicate a need to reevaluate the strategy. If the risk is still occurring, or if there are uncertainties about the effectiveness of the strategy, don`t take chances. Evaluate the strategy again to determine what can be modified.

The examples above are just a few of the many examples in a dental hygiene practice that warrant the use of risk management. Assess your workplace regularly to identify areas where risk management is needed. You are the only person who can ensure that your workplace habits exhibit safety, concern for the patient, and high standards of care.

Risk management is straightforward and systematic, yet flexible enough to adapt to the unique circumstances of a practice. Successful management of any risk results from purposeful planning, following an organized system, and staying abreast of current information. Risk management provides the vehicle for you to eliminate or minimize accidents, injuries, or lawsuits in your practice.

Linda Harvey, RDH, MS, is a licensed health care risk manager and consultant in Jacksonville, Fla. She may be reached at [email protected].

Suggested readings and resources:

Y Alty, C.T., RDH, 1996. Needles and the rush hour. RDH, vol. 16, no. 3, p. 15-18.

Y Devore, C.H., 1997. Legal risk management for the dental hygienist. The Journal of Practical Hygiene, Vol. 6, No. 4, p. 59-61.

Y Gurevitz, S.L., 1997. Erythromycin: Drug interactions. Journal of Dental Hygiene, Vol. 71, No. 4, p. 159-161.

Y Martin, C., Moore, D., Templin, K., and Moore, J., 1998. Electronic blood pressure screening: Fast, easy and essential. Access, Vol. 12, No. 1, p. 33-37.

OSHA resources:

Y OSHA home page: http://www.osha.gov/

Y OSHA Hazard Communication Standard web address: http://www.osha-slc.gov/OshStd_data/1910_1200.html

Y OSHA Blood Borne Pathogen Standard web address: http://www.osha-slc.gov/OshStd_data/1910_1030.html


Y Harvey, L.M., Principles of risk management. Home Study Educators, first edition, 1996, Miami, Florida.

Y Head, G.L. & Horn, S. Essentials of risk management. Vol. 1. Insurance Institute of America, second edition, 1991, Pennsylvania.

Y Jordan, S.L., Stowers, M.F., Trawick, E.G., and Theis, A.B., 1996. Glutaraldehyde permeation: Choosing the proper glove. American Journal of Infection Control, Vol. 24, No. 2, p. 67-69.