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Risk Management Considerations in Orthopaedic Practice

Orthopaedic surgeons encounter areas of potential medicolegal risk in their day-to-day practice, such as consent, pre-operative issues, site marking, documentation etc. This sample checklist is intended to support clinicians to enhance patient safety and reduce potential exposure to medicolegal risk.

We appreciate that our policyholders work in different environments and locations, and as such, are bound by the current practice in these environments. However, this sample checklist is intended to support you in enhancing your personal practice as well as informing you of issues your clinic or hospital may benefit from implementing.

A recent review of PMP cases notified between 2014-2020 identified that 27% of cases related to orthopaedic surgery, including joint replacements and arthroscopies. The review highlighted that medical errors, adverse outcomes and near-miss events can result from issues related to technical skill, clinical judgement, communication, documentation, clinical systems and more.

The following sample checklist provides high-level considerations, in several areas, for improving patient safety and reducing medicolegal risks in orthopaedic practice. A systematic review by Treadwell J R et al, 2014, suggests that surgical checklists, focussing on areas such as scheduling, consent, pre-operative verification, site marking and timeouts, can enhance patient safety and reduce the risk of serious adverse events. A study by Haynes A B et al suggests that following the introduction of the WHO Surgical Safety Checklist into operating rooms, there were marked improvements in surgical outcomes and a reduction in the rate of post-operative complications.

We hope this sample checklist may serve as a helpful tool for you when considering the organisational culture and commitment where you practice, and in determining whether you believe there may be gaps in current processes. Please note this list is not exhaustive. However, it is based on key learning points from PMP data analysis.

Do you adhere to a comprehensive informed consent process, conducting a meaningful discussion with the patient prior to an intervention, to enable the patient to make an informed choice in accordance with the GMC’s “Decision making and consent”? This will include details of the procedure, risks, benefits and alternatives.
Do you use open questions about work and family to explore what might be important to the individual patient?
Do you use plain language when talking to patients about procedures, treatment plans, anticipated benefits, potential risks and alternative therapies?
Do you document details of the consent discussion in the patient’s medical record?
Do you actively listen to patients without interrupting and repeat information to clarify meaning?
Do you ask patients to repeat, in their own words, their understanding of proposed treatment plans and informed consent discussions?
Are patient education materials written in plain language?
Do you use interpreting services for patients who have language barriers?
Do you actively communicate and collaborate with the clinical teams providing patient care (eg, primary care physicians, other consultants, etc)?
Do you perform a complete assessment for each patient, including establishing a differential diagnosis and considering appropriate diagnostic testing?
Do you include the worst-case scenario as part of your differential diagnosis?
Do you participate in “Mortality and Morbidity” review meetings or similar team learning processes to support clinical reasoning?
Do you ensure timely ordering of tests and consults to prevent problems associated with ruling out or documenting abnormal findings?
Do you review all diagnostic test results and consultative reports prior to filing them in patient records?
Are high-risk patients systematically tracked to avoid failures in follow-up and diagnosis?
Do you carefully consider repeated patient complaints or concerns when making clinical decisions about patient care and additional diagnostic testing?
Surgery or treatment
Do you conduct a thorough pre-procedure screening of patients for risk factors?
Do you follow evidence-based guidelines specific to your specialty?
Do you ensure that all appropriate health information for each patient is available prior to the start of a procedure, including the patient’s written and/or electronic records, relevant radiology, pathology investigations and results etc?
Do you verify that an exact description of the procedure, including site, level, side and digit, is listed on the theatre schedule?
Do you mark the incision site with an appropriate surgical site marker before the administration of sedation and/or anaesthesia, ensuring it is visual once the patient is positioned, prepped and draped?
Do you reconfirm consent with the patient prior to surgery, to ensure the patient fully understands the planned procedure?
Are necessary equipment and supplies inventoried and verified prior to the start of a procedure?
Are infection prevention and control best practices used to maintain the sterile field?
Are patient safety precautions utilised during each procedure (eg, proper positioning)?
Do you and your surgical team participate in a timeout before each procedure?
Does anaesthesia monitoring occur throughout each procedure?
Do you and your surgical team communicate about patient status throughout each procedure?
Is a qualified healthcare provider immediately available during patients’ recovery periods?
Do you maintain a consistent post-procedure assessment process?
Are patients appropriately monitored following procedures (eg, vital signs, airway, mental status, pain, hydration, etc)?
Are patients evaluated against discharge criteria prior to discharge?
Are patients and families/carers provided with appropriate education and instructions prior to discharge?
Do patients receive a post discharge follow-up call?
Does each patient’s medical record contain thorough and appropriate information, such as history and physical, current medications, non-pharmacological interventions, allergies, pain assessment, test results, consults/referrals, treatment goals, pre-operative screening results, etc?
Do you document the clinical decision-making process, treatment rationale and follow-up plan?
Do you document all telephone calls and electronic communications related to clinical care?
Do you document the informed consent process, including discussions of risks, benefits and alternative treatment options?
Are informed consent forms (if applicable) maintained as part of patient records?
Do you complete a detailed operative report on the day of the procedure?
Do you document all instances of patient non-compliance as they occur, as well as any education provided to patients and families/carers regarding the consequences of not following the treatment regimen?
Do you participate in peer review activities to improve performance and quality?
Do you continue to enhance your technical surgical skills and communication skills through continuing education?
Do you undertake regular audits of intervention outcomes as a quality improvement measure and address and document any shortcomings identified in audits?
Learning from events
If the patient experiences an adverse outcome following the surgery, do you investigate, explain and apologise to the patient, in accordance with professional duty of candour for individual clinicians and statutory duty of candour for healthcare providers?
In the event of an adverse event and/or patient complaint, do you use this as an opportunity to reflect, learn and adopt changes to your practice, to improve care? The reflection and learning from adverse outcomes will provide useful evidence for a doctor’s appraisal and revalidation.

Information correct at the time of publication February 2022

This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, please contact your solicitor, legal advisor or other professional advisors if you have any questions related to your legal or medical obligations or rights, applicable law, contract interpretation, or other legal questions. © 2022 Premium Medical Protection Ltd. All rights reserved.

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