The wrong tooth: extraction of 64 when 65 was the infected tooth
It is Friday, 3:40 pm, in a busy school dental clinic. The chart says 'extract 64' for Mihi, aged 9. The nurse reads 'extract 64' from the day sheet. Tooth 64 is restored and asymptomatic; the tooth with the large carious lesion and the buccal sinus is 65, and 65 is the tooth that has been causing two weeks of pain. The radiograph is on the screen but the room lights are dimmed and the chart was updated in a hurry at the end of a double-booked session. You give local anaesthetic and extract 64, placing it in a kidney dish. As you hand Mihi the mirror, you notice 65 is still in the mouth. Mihi's mother has already been told by reception that 'everything went fine' and is waiting outside.
1. What are your immediate and short-term actions, including what you say to Mihi and her mother?
Read the worked answer
Stop and check Mihi first: is she well, is haemostasis controlled, is she in pain? Then tell her, in terms she can understand, that you took out the wrong tooth by mistake and that you are sorry. Children deserve the truth in plain language, and it is better coming from you than overheard later.
Speak to the mother before she leaves the building, in a private space, with the clinical leader present if possible. Use open disclosure: what happened, why it happened at the level you can honestly explain, what it means for Mihi, what you will do next, and an apology. Do not blame the nurse or the day sheet. Right 5 of the Code of Health and Disability Services Consumers' Rights gives her the right to be told of an adverse event and to an explanation; Right 4(1) gives her the right to services delivered with reasonable care and skill. Tell her she can complain, and how, including the Nationwide Health and Disability Advocacy Service and the Health and Disability Commissioner.
Clinical follow-up: 65 still has an active infection and still needs treatment - this is not resolved by the error. Assess the 64 site and plan for space maintenance, since early loss of a second primary molar at 9 can lead to drifting and loss of space for the second premolar. Record everything contemporaneously and factually; do not amend earlier notes retrospectively.
Then complete an incident report the same day.
2. How would you go about reviewing what went wrong, and what system changes would reduce the chance of a repeat?
Read the worked answer
Treat it as a system problem, not a person problem. The nurse read the plan; you extracted the plan. The failure was in the process that produced the plan and in the checks before the forceps were picked up.
Look at the contributing factors honestly: the chart and day sheet both carried 64, meaning the chart had been updated incorrectly (or ambiguously) and nobody checked it against the radiograph and the clinical findings; the room was dim; the session was double-booked; there was no pause before the procedure; the child had no role in confirming which tooth hurt; nothing flagged that the planned tooth did not match the presenting complaint.
Practical changes:
- Use FDI two-digit notation consistently on the chart, the day sheet and the referral, and write the tooth name as well as the number.
- A pre-procedure pause before any extraction, at which the operator, assistant and the radiograph on screen are all checked against the stated complaint and the planned treatment.
- Show the patient or parent the tooth and get a verbal confirmation for irreversible procedures.
- Fix the booking template so elective extractions are not scheduled into the last double-booked slot on a Friday.
- Improve lighting and screen visibility at the chairside.
Share the learning with the team as a safety huddle or case review, without identifying individuals. Report through your organisation's incident system, and follow your policy on notifying serious adverse events, which may include the Health and Disability Commissioner. Finish the loop by checking that the changes are actually being used.
3. The mother is angry and says she wants to take the matter further. How do you respond?
Read the worked answer
Acknowledge the anger as legitimate rather than treating it as an obstacle. She trusted the service and her child has lost a tooth that did not need to come out, and still has the painful one.
Respond with: a clear apology for what happened, without excuses or defensiveness; a plain account of what you know so far, and honesty about what you do not yet know; a commitment to look into it and come back to her with the findings and the changes made; a named contact; and information about her right to complain to the Health and Disability Commissioner and to use the Nationwide Health and Disability Advocacy Service, offered in writing rather than buried in a sentence.
An apology is not an admission of legal liability, and withholding one to 'protect' the service usually makes a complaint more likely, not less.
Make sure she leaves with a plan for Mihi: how to contact the clinic over the weekend, what to do if the 64 site bleeds or becomes painful, and when 65 will be treated. Offer to ring her the next working day.
Afterwards, look after yourself and the team. Being involved in a harmful event is genuinely distressing, and a debrief with a colleague or through your employer's support process is part of safe practice, not a sign of weakness.