Orthopaedic Surgical Patient Safety- Role of the Orthopaedic Surgeon

                                   Dr. KS Dhillon

Introduction

Medical malpractice claims are relatively common. One study reported that 7.4% of physicians have a claim filed against them each year [1]. In the USA, the medical malpractice system accounts for about 2.4% of the health care spending at an estimated cost of $55.6 billion dollars yearly [2].

In the USA, more than 50% of orthopedic surgeons have been named as a defendant in at least 1 medical malpractice lawsuit [3]. 

There are 3 broad categories that lead to medical litigation. These include improper performance, inappropriate or negligent surgery, and patient dissatisfaction. Improper performance can include postoperative complications or technical errors such as inadequate fracture reduction. Negligent or inappropriate surgery may involve wrong diagnosis, delayed diagnosis, or failed diagnosis and wrong-site surgery. Patient dissatisfaction is defined as a patient’s perception of how successful a surgery was. It commonly involves patients claiming potential complications were not adequately explained or informed consent was not properly obtained [4]. Improper performance involving technical error has the highest number of plaintiff verdicts at about 30%. Most orthopedic claims stem from intraoperative events [5]. Hence it is important to prevent improper performance and negligent or inappropriate surgery. 

Orthopaedic Surgical Patient Safety and the role of orthopaedic surgeon

Both surgeon leadership and collaborative surgeon-hospital alignment is essential for the successful introduction and maintenance of surgical

safety programs. 

Patient safety (organised surgical error elimination) and quality (reliable, improving innovative surgical systems) are essential components of contemporary healthcare delivery systems. 

Surgical patient safety is defined as highly organized systems of

surgical care that is designed to minimize, with an ultimate goal to

eliminate preventable surgical harms. 

Safety is a critical core element of surgical quality. Surgical quality is 

defined as highly reliable, continually improving, and innovative surgical care systems that provide the best possible surgical outcomes. 

Leadership and collaboration among orthopaedic surgeons, hospitals, and healthcare systems are needed to foster the safest possible surgical environments and best-quality surgical patient care [6].

The following six important surgical safety elements have been identified based on the most frequent causes of surgical harm and error reported to The Joint Commission (TJC) Sentinel Events Database: 

1. Communication

2. Concentration

3. Collection

4. Consent

5. Checklists,

6. Confirmation

Knowledge and regular use of these six elements in orthopaedic practice reduces preventable surgical harm and improves orthopaedic surgical care.

1. Communication

Effective communication is important for good surgical team performance. There has to be safe surgical communication. This would require transparent dialogue and effective teamwork among the preoperative, operative, and recovery surgical team members.

Critical care team training programs have improved surgical performance and safety outcomes in the operation theater and perioperative

settings [7,8,9,10]. 

Teamwork behaviors can be improved through the use of surgical briefings and debriefings, improved situation monitoring as well as mutually supportive team communication [9,10]. Successful team training programs focus on team commitment to shared knowledge, attitudes, and skills. These improvements in teamwork rely on the team’s willingness to cooperate and communicate effectively while focusing on the goal of achieving an optimal outcome for every patient. The surgeon, who is the team leader sets the tone and fosters the sustainability of effective, efficient, and transparent team communication.

2. Concentration

Surgical team members concentration fosters focused surgical team performance without distractions. Simple interruptions among surgical team members can cause increased errors through alteration and disruption of normal surgical team workflows. One study showed that unessential nonurgent communication during surgery made up 26% of stressors to the surgeon [11]. 

3. Collection

There has to be regular ongoing collection of surgical safety, quality, and

outcome data. This will provide the foundation for surgical performance assessment. Reporting of preventable harm by surgical team members, including surgeons is not common [12,13].

Data on the effects of interventions, such as checklists on complications and mortality will be useful to evaluate their efficacy [14]. 

For an effective surgical safety program, complete and systematic reporting

of preventable harm incidents by surgeons and surgical team members is essential. Incomplete data reporting undermines safety. 

4. Consent

Consent for surgery is critically important for patient safety, as well as patient satisfaction and understanding. The consent document is used many times by the surgical team members as a key reference for surgical procedure, site, and patient confirmation during the universal protocol process. The consent has to be accurate, legible, and understandable. It has to be entered into the patient record in a timely manner before the surgery. The consent process is an important element of patient-centered care and patient-surgeon communication.

The surgical information provided to patients should consider their best interest, competence, and level of understanding [15,16]. 

A study by Crepeau et al [17] showed that the comprehension and immediate recall after informed consent of patients undergoing orthopaedic surgery were unexpectedly low. The preoperative recall rates were accurate in only 71% of cases. At the time of the first postoperative visit, the recall rates drop to about 59.5%. The postoperative recall was particularly low for older patients (53.8%) and less educated patients (53.7%). The orthopaedic surgeons can improve patient understanding by testing recollection at key points during the consent discussions.

Miller et al [18] carried out a study where patient recall was tested with a new consent requiring patients to describe the planned surgery in their own words. This increased patient participation and satisfaction as compared to the traditionally passive consent process. 

There are several orthopaedic studies [19,20,21] that have demonstrated that multimedia educational tools improve consent recall, particularly if the format is patient-centered and patient-interactive. Another study

showed, that if the time spent on the consent process was at least 10 minutes, patient comprehension improved by 7% and the repetition of key consent elements increased comprehension by an additional 3% [22]. 

5. Checklists

Checklists are validated, evidence-based, or consensus-based standardized surgical processes. The Joint Commission supports checklists as a component of their Universal Protocol initiative. This protocol requires procedure verification, surgical site marking, and a time-out performed before the surgical procedure [23]. The World Health Organization has demonstrated the utility and effectiveness of checklists in their Safe Surgery Saves Lives program [24,25]. Checklists improve communication among the operation theater staff and doctors. An analysis of patient safety incidents in the United Kingdom National Health Service showed that 21% of orthopaedic wrong-site surgery, including 83% of cases with harm, could have been prevented with the use of the WHO surgical checklist [26].

6. Confirmation

Confirmation is the accurate and timely verification of the surgical site, level, side, procedure, implant, and patient. Generally, compliance with proper surgical site verification and confirmation in orthopaedic has been reported as inconsistent or absent.

A study by Johnston et al [27] showed that the surgical timeout was performed before skin incision in only 70% of cases, after skin incision in 19%, or not at all in 11% of cases. Wrong-site surgery continues to occur in orthopaedic surgery. The rate of wrong-site surgeries reported by candidates to the American Board of Orthopaedic Surgery from 1999 to 2005 did decrease during 2006 to 2010, but the improvement was not statistically significant. Despite compliance monitoring since 2007, surgery involving incorrect sites, levels, implants, sides, procedures, and patients continues to be reported at nearly the same rate [28].

Six important surgical safety program elements to eliminate preventable surgical harm have been identified. These include:

1. Effective surgical team communication

2. Proper informed consent

3. Implementation and regular use of surgical checklists

4. Proper surgical site/procedure identification

5. Reduction of surgical team distractions, and

6. Routine surgical data collection and analysis to improve the safety and quality of surgical patient care.

Conclusion

Medical malpractice claims are relatively common. There are 3 broad categories that lead to medical litigation. These include improper performance, inappropriate or negligent surgery, and patient dissatisfaction.

Most orthopedic claims stem from intraoperative events [5]. Hence, it is important to prevent improper performance and negligent or inappropriate surgery.

The orthopaedic surgeon is a key leader who works with the surgical team

members in the hospitals to ensure safe and optimal surgical patient outcomes. There are six key surgical safety elements i.e communication, consent, checklists, confirmation, concentration, and collection. Orthopaedic surgeon leadership, combined with hospital alignment and collaboration is required to share these common goals, responsibilities, and vision that promotes and maintains the safest possible environment for every patient.

References

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