Minimise Risks in Elbow and Shoulder Surgery

The following guidance offers risk management tips to assist you in mitigating risks associated with elbow and shoulder surgery, minimise the risk of litigation and enhance patient safety.

Risk management tips

1. Informed consent

In accordance with the GMC’s Decision making and consent, you should ensure you have a meaningful discussion with patients prior to any procedure to enable them to make an informed choice. This should include providing relevant information to the patient in the form of additional literature or reference to online resources to ensure they fully understand what the suggested surgical procedure entails as well as the risks, benefits and alternatives to the procedure or treatment. In addition, listen to the patient, and respond to their concerns and preferences. Always ensure you consider what is most important to the individual, taking into account their lifestyle and employment.

• Provide supplementary information via leaflets and trusted websites and record this in the patient’s medical records.
• Ensure that the information shared with patients about the options for treatment is objective.
• Document in detail the content of your discussion in the patient’s medical record, including any discussion regarding the risks/benefits specific to the patient’s individual circumstances.
• On the day of admission, recheck the patient understands the intervention and allow time for any further questions. Document this discussion in the patient’s record.
• Provide the patient with a consent form to sign detailing the procedure and the associated risks and benefits.
• Keep a copy of the consent form in the patient’s medical records and provide the patient with a copy.

2. Communication

• Use layman’s terms when discussing procedures, treatment plans, anticipated benefits, potential risks, and alternative therapies.
• Use a comprehension technique — such as teach-back — to gauge patient understanding and reduce the risk of miscommunication.
• Prior to discharge, provide patients, families and caregivers with appropriate instructions about wearing slings, pain relief, wound care, physiotherapy, driving restrictions etc. Record this advice in the patient’s medical records.

3. Funding

• If the patient is self-funding, provide them with clear information about all the costs, including those associated with post-operative follow-up.

4. Surgery

• Conduct thorough pre-procedure screening for risk factors.
• Ensure that all appropriate health information for each patient is available prior to starting a procedure.
• Satisfy yourself that all necessary equipment and supplies are inventoried and verified prior to starting a procedure.
• Verify that the site of surgery is marked correctly, and involve the patient in this process when possible.
• Minimise the risk of team communication breakdowns by encouraging team members to speak up about safety concerns.
• Participate in surgical team timeouts prior to commencement of surgical procedures and complete the WHO Surgical Safety Checklist.
• Avoid implant selection errors with the introduction of intraoperative ‘stop moments’ before implantation and wound closure to check all implant details and ensure compatibility of each component. In addition, please refer to PMP Wrong Size/Wrong Site Prosthesis for Joint Replacements.
• Follow the recommendations in the NICE guideline on the prevention and treatment of surgical site infections.
• Carry out consistent post-procedure assessment processes.

5. Handover

• Allow adequate time for handover, prioritising tasks and plans for care and review of unstable patients.
• Ensure any post-operative deterioration or complications are communicated, investigated, and managed in a timely and appropriate manner.
• Record details in the patient’s medical records.

6. Duty of Candour

• If a patient experiences an adverse outcome, it is important to investigate, explain and apologise to the patient. For further guidance on your ethical obligations, please refer to GMC guidance, Openness and honesty when things go wrong: The professional duty of candour.
• If you receive a complaint from a patient or a patient suffers an adverse event, please call the PMP medicolegal helpline as soon as possible. The PMP medicolegal helpline team is provided by Clyde & Co LLP (a law firm) and can assist customers in preparing an appropriate response.

7. Learning from events

• An adverse event should be used to reflect, learn, and adapt changes to a clinician’s practice and ultimately improve care.

8. Record keeping

• Maintain clear, detailed, and accurate medical records.
• Document a complete, concise, and accurate operative report on the same day of each procedure. Ensure all entries are dated, timed, and signed.
• The importance of good contemporaneous records cannot be overstated. If a patient raises a complaint or clinical negligence claim, these records will form the basis of your medicolegal defence.

9. Training and performance improvement

• Expand clinical training opportunities (eg, simulation surgical techniques and coaching on technical, safety, and teamwork skills).
• To standardise processes, improve efficiency, and support quality of care, clinicians should follow evidence-based guidelines and clinical pathways, such as BESS Total Elbow Replacement Surgical Procedure Guide.

10. Professional indemnity insurance

• Ensure adequate professional indemnity insurance is in place to cover all interventions undertaken. Please remember that, in accordance with the terms and conditions of your insurance policy, you must advise PMP of any changes to the scope of your practice. Your insurance cover may be impacted if you do not inform us of such changes.