After months of reviewing cases in which something went wrong as dentists administered anesthesia to patients in Texas, a blue ribbon panel appointed by the Texas State Board of Dental Examiners has come out with recommendations for how the board can better monitor dentists who provide sedation and anesthesia.
The blue ribbon panel review was ordered by the Texas Sunset Commission last year after a number of cases came to light, including the infamous story of Nevaeh Hall, a four-year-old Houston girl who sustained serious brain damage while under the care of Dr. Bethaniel Jefferson in January 2016.
The Texas State Board of Dental Examiners has come under frequent fire from the Sunset Commission over the years. First it was summarily abolished during its Sunset review in 1993 because of a legislative skirmish the board had been dragged into. It was revived in 1995, but was then placed under another Sunset review in 2003 because there were concerns about “serious enforcement deficiencies,” according to the Sunset Commission report issued in April 2016.
The State Board of Dental Examiners underwent a review last year as well, and once again was found wanting by the Sunset Commission, especially when it comes to how the agency handles anesthesia regulation. In response the commission ordered the board to form a ten-member blue ribbon panel of dentists that would review cases of dental anesthesia deaths and mishaps over the past five years, as well as evaluate emergency protocols.
After holding four open-to-the-public meetings last year, the panel presented its findings to the state Legislature this week.
The panel concluded that the reasons patients die or become permanently disabled in connection with dental care are varied. In the cases it reviewed, most of the deaths were not directly related to mishandled sedation or anesthesia, but each of the most serious cases reviewed included at least one failure on the part of the person providing the anesthesia.
In each of the 78 cases in which something went wrong, the people providing anesthesia all skipped core practices tied to properly administering anesthesia, the report concludes. This includes everything from not doing good preoperative review of the patient or not doing a good job of actually giving the anesthesia to not monitoring the patient closely enough and not handling the actual emergency situation well once they became aware there was an issue.
In all six of the cases identified by the panel as "major events," meaning the patient either died or was permanently damaged and the issue was directly tied to mishandled anesthesia, there were at least two of these major failures, the report states.
However, the panel concluded that if the current rules in place had actually been followed in each of these cases, there wouldn't have been a problem. The panel acknowledges that because of this, it's more difficult to know how to remedy the situation.
The panel came up with a number of recommendations advising that the State Board of Dental Examiners should have the authority to conduct inspections of dentists who administer sedation and anesthesia. (Right now 36 states have some level of this type of office inspection, but Texas is not one of them.) The panel suggests these visits focus on looking at whether or not the dentist can competently use anesthesia.
The panel also proposes giving the board authority to review sedation records, and if the records are not being kept up to date, the board would be able to use that as an indicator that an office visit might be needed.
The panel also advises the board to mandate that written emergency protocols be kept on site and that the staff must practice these six times a year. This would go a long way toward making sure that in the event of an emergency, the staff is ready to handle it well. Members also recommended the state board require providers who want to give children or high-risk adults anesthesia undergo documented training that is specifically aimed at managing each type of patient.
The panel also suggested that the state board should work on collecting data on all the anesthesia dentists perform in Texas and require that the anesthesia records be a part of the dental records so that all the information about the procedure is recorded. The study observes that right now there's not enough data about dental anesthesia procedures in general to provide a scientifically valid data pool to help draw larger conclusions or to see if isolated incidents could be a part of broader trends.
But keep in mind that while these ideas all sound reasonable enough, there's the not-so-slight question of how exactly the State Board of Dental Examiners would undertake to do these inspections and increase how much dentists are monitored in the first place or pay to put any of this advice into action.
As we've noted before, there's no funding to hire inspectors to inspect dental offices and ensure dentists are performing sedation according to the rules. The legislature may decide to kick some funding to the board to allow more office inspections, but we already know the state is going to be on a very tight budget this time around.
So the recommendations have been made. Now we have to see if anyone actually does anything to put these, along with some other proposals the panel came up with, into practice.
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