By Jacqueline Ross and Eric E. Cleckler

Jacqueline Ross is coding director, and Eric E. Cleckler is patient safety risk manager, The Doctors Company, Part of TDC Group.

During a total hip replacement, a patient experienced a brisk bleed and a drop in blood pressure that required intervention from the anesthesiologist. There was a discrepancy in the documented estimated blood loss, with the surgeon noting 30 0cc while the anesthesiologist recorded 1100 cc. The patient was hypotensive in the PACU and had a discolored leg with no pulse. The patient decompensated, and the orthopedic surgeon consulted a vascular surgeon. The patient returned to the operating room. The vascular surgeon found a severe injury with bleeding in multiple arteries and considered it a possible crush injury to arteries from a retractor; the vascular surgeon controlled the arterial injury. With the femoral flow restored, the patient did not require a fasciotomy. However, the patient developed infections, needed multiple surgeries, and eventually had an above-the-knee amputation. Litigation ensued.

New study

Orthopedic surgery is a specialty that emphasizes technical performance, necessarily—but not exclusively. Our analysis revealed that careful attention to patient selection up-front and communication throughout the course of treatment, also offers surgeons substantial protection from litigation risks.

Technical performance

Allegations of improper management of the surgical patient also featured prominently in our study. This “improper management” category incorporates the management of the patient along the entire surgical continuum of care (preoperative, intraoperative, and postoperative phases). Roughly one-third of the studied claims included an allegation in this domain of care, and 28 percent of the improper management claims resulted in a settlement.

Other contributing factors

The combined mass of allegations of poor technical performance or improper management might create the impression that risk management in orthopedic surgery is entirely about technical mastery. In fact, however, the picture is more complicated, because prominent contributing factors included the selection and management of therapy (18 percent of studied claims) and communication between the provider and the patient/family (19 percent of studied claims). These discoveries emphasize the importance of patient selection and thorough communication regarding expectations.

Risk mitigation strategies

As many clinicians have experienced, patients who have poor communication with their health care teams can be less likely to adhere to recommended treatments or complete diagnostic testing procedures and referrals and may be more likely to miss follow-up appointments. These types of behaviors may place the patient, health care professional, and organization at risk.

Adding to these difficulties, meeting and/or managing patient expectations is often challenging. Patients seeking relief from pain may let their hope outweigh information about known complications, potential less-than-ideal outcomes, or a treatment recommendation that is different from the one they expected.

It is always worth communicating a treatment plan’s risks, benefits, and alternatives (RBAs) to help establish reasonable expectations. Ensure the patient is well-informed and understands their decision. Documentation of the RBA discussion and signed consent—or a documented refusal to consent, for the patient who will not adhere to instructions for follow-up care—could help mitigate risks, should a claim occur.

The big picture

To learn more, read the study.