When patients are angry: de-escalation and risk mitigation are essential tools

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In some situations, anger can be a good thing. It can provide an outlet for expressing negative feelings or motivating the search for solutions to problems. But when an angry patient shows their feelings through threatening behavior like yelling, swearing, harassment, or even violence, practice owners need to step in. As employers, they are required to provide their staff with a safe working environment, in which employees do not fear for their own safety. Care should be taken to treat threats to staff welfare as seriously as threats to the practice owner.

The Dentists Insurance Company’s Risk Management Advice Line, which provides advice to TDIC policyholders and members of dental associations, has recently received an increasing number of calls about patients who are overly aggressive. or who show unreasonable anger towards dental providers and staff.

Risk management analyst Shelli Macaluso reports: “We are getting calls where patients refuse to leave the office and act aggressively, using profanity and making threatening statements while other patients are present. Staff members are generally fearful. Unfortunately, these issues can escalate to the point where staff and practice owners feel threatened.

The following case studies illustrate how TDIC’s risk management analysts have advised practice owners to respond when patient behavior changes from anger to aggression and even outward displays of threats or physical actions.

First case study

In a recent call, an adult patient accompanied by both parents – as they had been on previous visits – was seen with pain in tooth #9. The dentist recommended a crown due to a gingival crest fracture and placed a temporary crown. . The patient was warned that the temporary crown had little retention due to the lack of remaining tooth structure and could loosen or fall out. Therefore, the dentist encouraged her to see the endodontist as soon as possible, as the existing root canal would need to be retreated.

A few days after the initial treatment, the patient’s mother called the general dentist to request an immediate appointment, stating that the crown had indeed come loose. The office gave him an afternoon appointment the same day. The patient arrived an hour early, accompanied by her mother, and began loudly demanding that the dentist fix the tooth immediately. The patient and her mother said they were unwilling to comply with the endodontic recommendation and insisted that the dentist “fix” the tooth instead.

Despite the dentist’s assurance that she would see the patient at the scheduled time of her appointment, the mother grew increasingly hostile. There was a waiting room full of patients and every operating room was full.

The mother became more aggressive as she waited with her daughter, causing disruption and concern for other patients and staff. The dentist acknowledged that the matter was getting worse and asked a member of staff to call the police. When the police arrived, the patient’s mother continued her tirade and refused to leave. The officer explained to the parent that his refusal to leave would be treated as an unlawful trespass on private property and ordered him to leave the premises immediately. She again refused, so the officer informed the mother that his next action would be to handcuff her and remove her from the premises.

At this point, the patient and the parent agreed to leave. Unfortunately, before leaving, the parent saw a staff member reporting the events to the police and reached out and punched the staff member, which resulted in the parent being arrested by the attending police officer.

When the dentist contacted the TDIC advice line, the risk management analyst who took the call assured him that contacting law enforcement had been the best choice and recommended that next steps be taken. immediate discharge of the patient and reimbursement of the crown. The dentist did not hesitate to contact the police, but feared the patient was halfway through treatment. Considering the irrational and violent behavior of the mother, the dentist asked if the mother would now allege that the patient had been abandoned. The analyst advised the dentist that in this case the dismissal was justified despite the fact that the patient was undergoing treatment. Although the aggressive mother was not a patient, she constantly accompanied her daughter to appointments and clearly posed a threat to staff safety.

The analyst reminded the dentist that as an employer, she has a responsibility to keep her staff safe and to prevent exposure to this kind of hostility. The parent was angry enough to physically assault a staff member. Consequently, injury to patients or staff could occur in the future.

Second case study

In another case, the advice line received a call from a dentist in the middle of a escalating situation.

In this scenario, a tall, muscular male patient who was known to be very afraid of dental work showed up for his appointment. The dentist and her assistant always spent time trying to comfort the patient and minimize his anxiety. During the call to the helpline, the dentist explained to the analyst that despite the red flags and signs that the patient might become hostile when upset, she really wanted to help. Before the treatment, the assistant raised her concerns with the dentist and was nervous about being near the patient given his intimidating size and what appeared to be a tendency to escalate his behavior towards physical interaction. The dentist assured the assistant that they were not in danger.

The dentist proceeded with the treatment, communicating to the anxious patient that she would be as gentle as possible with him. She warned him that he might feel some slight discomfort during the injection of the anesthetic. During the injection, the patient violently grabbed the dentist’s hand and squeezed it hard enough to cause pain. She pulled out the needle and tried to calm him down unsuccessfully.

At this point, the patient jumped up, aggressively walked towards the dentist, and began angrily accusing him of intentionally causing her pain. The dentist assured the patient that she had not intentionally hurt him, but the more she talked, the angrier he became. The dentist offers the patient time off until he can calmly discuss his treatment.

The patient left the treatment area, but then entered the reception area where he continued to behave in a manner that upset and frightened office staff. He eventually left the building but lingered outside the office for a long time, pacing while staring angrily at the windows, prompting the dentist to call the advice line.

The risk management analyst recommended that the dentist contact law enforcement immediately given the patient’s outward expression of anger, physical interaction with the dentist, and threatening behavior outside of the clinic. firm. Again, this was a situation that warranted the patient’s immediate discharge, so the analyst guided the dentist through proper documentation and communication.

As a result of her experience with this patient, the dental assistant felt traumatized and later asked to open a workers’ compensation claim as she continued to experience anxiety while caring for the patient. after the incident. In hindsight, the dentist realized that minimizing her assistant’s concerns about this patient posed an unnecessary risk to the entire practice.

De-escalation and mitigation

Patients and accompanying family members or friends can pose a threat to dentists, staff and other patients when their emotions lead to aggressive behavior. Heightened emotions should never be taken lightly. Physical and verbal threats should be treated with equal caution, as there is no way to predict how far (or quickly) a situation will escalate.

Some key communication strategies are important when dealing with angry or aggressive patients.

  • Set limits. Have clear behavioral expectations for patients and staff, and planned responses when someone crosses those boundaries.
  • Stay calm. Always respond with a professional demeanor.
  • Be understanding and empathetic. Listening is an essential part of communication. Let upset patients know you’re ready to listen. “Sometimes patients just want to be heard,” says Taiba Solaiman, Senior Risk Management Analyst. “Sit down with them privately and let them know you understand they are upset and are ready to listen to their concerns. A sympathetic ear can go a long way to clearing up a tense situation.
  • Remember the documentation. Just as you take careful notes regarding treatment in a patient’s chart, you should document any conflict that arises with a patient.
  • Know when to contact law enforcement. It may not be necessary to contact the police every time a patient is upset or conflicted. However, when a patient refuses to leave the office when asked to do so or engages in behavior including but not limited to harassing staff by repeatedly calling, threatening to show up to the office and harming or physically interacting with anyone in the office, the police should be called to intervene. (If you are not in immediate danger, it is advisable to seek advice from the Risk Management Advice Line when these situations arise).

Dealing with disgruntled patients can be an unfortunate reality for practice owners and, as these incidents demonstrate, they have increased in recent years. In the rare event that anger escalates into aggression, be aware of your obligation to provide a safe work environment for your employees. Also be aware of the anxiety you and your employees may feel after a traumatic event and provide support resources. Seek assistance from law enforcement to help de-escalate the situation when needed and seek expert support from TDIC’s risk management analysts to help you properly exclude a patient from care.

The TDIC Risk Management Advice Line is a benefit of CDA membership. Schedule a consultation with an experienced risk management analyst or call 1.877.269.8844. Reprinted with permission from the California Dental Association, copyright August 2022.

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