Minimise Risks in Urology

As a urologist, you face various risks in your day-to-day practice. Of course, we know you always aim to deliver the best possible care to each patient. However, when a procedure or course of treatment does not end as planned and an adverse outcome follows, this can result in significant consequences for both patient and clinician. Adverse outcomes related to surgical treatment and diagnosis can result from a variety of factors, including issues with technical competency, clinical judgement, communication, and documentation.

The following guidance offers risk management tips to assist you to mitigate the risks associated with surgery, reduce your risk of facing 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 the patient prior to the procedure. This will assist the patient to make an informed choice. This discussion should include details of the surgical procedure and the risks, benefits and alternatives associated with it. In addition, consider what is important to the individual patient, taking into account their lifestyle and employment.
• Document in detail the content of your discussion in the patient’s medical record.
• 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 and ensure it is dated.
• Provide the patient with a consent form to sign, detailing the procedure and the associated risks and benefits, together with any issues which were highlighted in discussions with the patient which are specific to them as an individual, i.e. impact on work/family life etc.
• Keep a copy of the consent form in the patient’s medical records and provide the patient with a copy.

2. Communication

• Communicate adequate, clear, and appropriate information to patients, using layman’s terms when talking about surgical procedures, anticipated benefits, potential risks, and alternatives.
• Offer an interpreter to assist with patient communication and comprehension where patients have limited English proficiency or disabilities.
• Use a comprehension technique — such as teach-back — to gauge patient understanding and reduce the risk of miscommunication.
• Provide patients, families and caregivers with appropriate education and instructions prior to discharge. Ensure the instructions are recorded in the patient’s medical records.

3. Funding

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

4. Surgery

• Review patient selection criteria for each procedure and conduct a thorough pre-operative screening of patients for risk factors. Use a validated risk stratification tool to supplement clinical assessment when planning surgery.
• Follow the NICE guidance on assessing and reducing the risk of venous thromboembolism.
• Ensure strategies are in place to minimise team communication breakdowns and encourage team members to speak up about safety concerns.
• Be aware of common cognitive and affective biases and how they might negatively affect your clinical judgement.
• Participate in surgical team timeouts prior to the commencement of surgical procedures and completion of the WHO Surgical Safety Checklist.
• 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 the care and the review of clinically unstable patients.
• Ensure any post-operative deterioration or complications are communicated, investigated, and managed in a timely and appropriate manner.
• Record the details in the patient’s medical records.
• A good handover process facilitates safe and efficient practice.

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, provided by Clyde & Co LLP (a law firm), can assist customers in preparing an appropriate response.

7. Learning from events

• An adverse event should be used as an opportunity for you and your team to reflect, learn, and adapt changes to your practice and ultimately to improve care.

8. Record keeping

• Consider using a checklist or template as a guide when taking each patient’s medical history and performing a thorough physical examination. In a busy healthcare environment, these tools can help ensure consistency of approach and may help prevent oversights.
• Document a complete, concise, and accurate operative report on the day you perform each procedure. Ensure the entry is dated, timed and signed.
• The importance of good contemporaneous records cannot be overstated. In the event that a patient raises a complaint or a clinical negligence claim against you, these records will form the basis of your medicolegal defence.

9. Training and performance improvement

• You should engage in performance improvement opportunities and peer review activities to enhance your technical surgical skills, ensure continued competency and improve performance and quality.
• In order to standardise processes, improve efficiency and support quality of care, surgeons should follow evidence-based guidelines for specific procedures, for example, Vasectomy and clinical pathways.
• Expand clinical training opportunities (eg, simulation to practice surgical techniques and coaching on technical, safety, and teamwork skills).
• If you perform robotic-assisted surgery, ensure that all surgical team members who use this technology are aware of key risks related to this intervention, such as training, competency, patient selection and informed consent. Developing a greater awareness of the particular risks associated with this type of surgery and establishing standards and best practices will help enhance patient safety and reduce the risk of litigation. Please see PMP Risk Tips for Robotic-Assisted Surgical Procedures.

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.