General Surgery Risk Tips Featured

Minimise Risks in General Surgery

PREMIUM

Adverse outcomes related to surgical treatment and diagnosis can result from a variety of factors, including issues with technical competency, clinical judgement, communication, documentation, and more.

A review of PMP cases notified over a six-year period identified that a significant number related to general surgical procedures, of which 29% were associated with breast surgery and 21% with hernia operations.

A number of contributing factors were identified, including lack of informed consent, poor clinical judgement, competency issues and poor communication with patients.

The following guidance offers risk management strategies to assist you to mitigate the risks associated with general surgery, reduce the risk of litigation and enhance patient safety.

Risk management strategies

1. Training and performance improvement

  • Consultants should engage in performance improvement opportunities and peer review activities to continually enhance technical surgical skills, ensure competency and improve performance and quality.
  • In order to standardise processes, improve efficiency, and support quality of care, clinicians should follow evidence-based guidelines and clinical pathways.

2. Informed consent

  • In accordance with the GMC’s Decision making and consent, surgeons should ensure they have a meaningful discussion with the patient prior to the procedure to enable the patient to make an informed choice. This should include details of the surgical procedure, risks, benefits and alternatives. In addition, consider what is most 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.
  • Keep a copy of the consent form in the patient’s medical records and provide the patient with a copy.

3. 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.
  • Discuss lifestyle modifications with people prior to having surgery eg, stopping smoking and reducing alcohol consumption.
  • Use a comprehension technique — such as teach-back — to gauge patient understanding and reduce the potential risk of miscommunication.
  • Provide patients and families/caregivers with appropriate education and instructions prior to discharge. Ensure the instructions are recorded in the patient’s medical records.

4. 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.
  • Ensure the patient is aware of their right to a refund or return of deposit if they change their mind about the proposed treatment.

5. 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 clinical judgement.
  • Participate in surgical team timeouts prior to 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.
  • Focus on ‘closing the loop’ with regards to receiving, reporting and acting on test results.
  • For people with a high risk of complications or mortality, reduce the incidence of adverse events by providing post-operative care in a high-dependency unit or intensive care unit.

6. Handover

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

7. Duty of candour

  • If the 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.
  • The PMP medicolegal helpline is available 24/7 and is provided by Clyde & Co. The helpline team can assist policyholders with drafting a response in such circumstances.

8. Learning from events

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

9. 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 in 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.
  • These contemporaneous records will form the basis of any medicolegal defence, should this be necessary.

10. Professional indemnity insurance

  • Ensure adequate professional indemnity insurance is in place to cover all interventions undertaken. You must inform PMP immediately, in line with the terms and conditions of your policy, of any changes to the scope of your practice.

Information correct at time of publication April 2022

This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. We recommend that you seek independent legal and/or professional advice in relation to your legal or medical obligations or rights. Premium Medical Protection Limited is the owner of this material and its contents are protected by copyright law ©2022. All such rights are reserved.

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