Risk Management for Orthopedic Surgeons

Good preparation, thorough follow up, and compliance with informed consent requirements can help reduce risk in orthopedic practice. This page outlines key considerations for orthopedic surgeons, providing practical strategies to enhance patient safety and minimize liability risks.

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Patient history

A comprehensive patient history serves as the foundation for safe and effective care. When taking a patient history, consider both orthopedic and non-orthopedic conditions that might affect treatment decisions. This includes: 


• previous surgical procedures and complications, including any complications related to anesthesia;
• history of heart or cardiovascular disease;
• family history of vascular disorders and cancers;
• current medications, including over-the-counter drugs and supplements;
• allergies and adverse reactions to medications or other agents;
• anticoagulation status;
• any history of sleep apnea; and
• social history, including alcohol consumption and dietary habits.

Document conversations and findings in detail, noting both positive and negative responses to key screening questions. This documentation can prove invaluable if questions arise later about treatment decisions.

Informed consent

An effective surgical informed consent process means the surgeon must disclose to the patient the most common inherent risks of the treatment that could influence a reasonable person in making an informed decision to accept or refuse that treatment.

While consents are often signed at the hospital or surgical center the day of the procedure, it is prudent for the surgeon and patient to discuss the potential risks and complications well in advance of the procedure if possible.

• The surgeon performing the procedure, not a delegated representative, is responsible for making sure that the patient gives informed consent.
• Document the discussion in the medical record, including the risks, benefits, and alternatives to the surgery or procedure.
• When obtaining consent, use descriptive, non-medical terms to ensure patients understand complicated procedures. A good practice is to use key repetitive phrases, and ask patients to repeat what you have said.
• If there is a possibility that a procedure might need to be changed during surgery, include this in the consent forms and discuss with the patient.
• If others, such as family or friends, are with the patient during the informed consent discussion, document their presence in the patient’s record.
• If the patient declines surgery or other treatment, document their refusal, the discussion you had outlining risks of refusing care and any alternative treatments available. At your discretion, depending on the perceived risk of the patient declining care, you may wish to consider having them sign an informed refusal of care document.

Some states have rules and regulations regarding informed consent for procedures. For example, in Texas, informed consent is governed by statute and is overseen by the Texas Medical Disclosure Panel (TMDP). The panel includes physicians and attorneys who determine which procedures require informed consent and which do not. Procedures and treatments are then assigned to those requiring disclosure of specific risks and benefits List A, or those that do not require disclosure of risks (List B).

The TMDP also develops specific disclosure and consent forms to be used by Texas physicians. The lists, TMDP rules, and forms can be viewed here.

Tracking and follow up

Having reliable tracking and follow-up systems is crucial for managing patients before and after surgery. When referring patients to consultants or sending them for lab or diagnostic tests to obtain surgical clearance, use a tracking system to ensure the patient was seen, tests performed, and results received.

Tracking systems vary from practice to practice based on needs and available resources. Yet, the basic steps for managing patient test results and consults remain the same:


1. Track tests and consults until results are received.
2. Review the results and recommendations before they are added to the patient’s record, or make sure all results are on regularly checked “pending” review lists in the EMR.
3. Notify patients of the results and document that notification occurred.
4. When needed, ensure these results are communicated to other treating physicians so the patient can receive the recommended follow-up care. (1)

The preoperative period is also an ideal time to determine and document who will manage medications that must be stopped before and resumed after surgery (such as anticoagulants). This includes who will monitor any symptoms patients experience during this interruption.

Pre-surgical appointments provide an opportunity to discuss the patient’s expectations, provide detailed pre-operative instructions, and address any questions or anxieties about the procedure.

Care and attention to transitioning the patient safely out of the hospital or surgical facility is critical. Consider these additional risk management strategies.

• Ideally, operative reports and dictation should be completed as soon as possible after a procedure. Incomplete or late documentation can compromise patient care, as other physicians will not have access to information needed for treatment decisions and continuity of care. This gap in communication could lead to duplicate testing, medication errors, or missed follow-up care.

• If you use operative note templates, be sure that templates are updated appropriately to reflect the specifics of the procedure performed. 

• If complications are encountered during a procedure, be sure they are thoroughly documented in the operative note.
• Patients may be more susceptible to medical errors during the transition of care between inpatient and outpatient settings. Surgeons are encouraged to consistently communicate with the outpatient providers, particularly if there is critical information that could affect the patient’s care.
• Document any discussions with consulting physicians and hospital/surgical center staff about a patient’s test results, treatment, and recommendations.
• If patients experience complications after the procedure, carefully document any deviation from expected recovery. Track and document wound healing or other recovery milestones. Document the patient’s progress in comparison to previous findings.
• Ensure patients know when to follow up with you after leaving the hospital or surgical center. Provide clear, written instructions with specific dates or timeframes and information about post-operative follow-up appointments and criteria for seeking immediate medical attention. Verify understanding by having patients verbalize the follow-up plan before discharge.
• Once patients are discharged from the hospital, coordinate care with their primary care physicians as needed. Send pertinent medical records — discharge instructions, medication lists, and postoperative care plans — to facilitate effective communication between all health care providers involved in the patient's recovery.

Supervision

With the greater incorporation of advanced practice providers (APPs) such as advanced practice registered nurses (APRNs) and physician assistants (PAs), into collaborative practices, physicians should clearly understand the regulatory requirements that come with supervising APPs.

Consult your state medical board for the specific rules and laws that govern supervising these employees. For Texas physicians, rules regarding the supervision of APPs can be found in the Texas Medical Board rules chapters 183 and 169 of the Board rules, and the Texas Occupations Code Chapter 157.

If working in a supervisory or collaborative role with an APP, consider the following steps to lower risks associated with supervising APPs.

Establish a supervisory agreement or collaborative care plan. The plan should detail the working arrangements between the APP and the physician/practice, including methods of communication, scope of responsibilities, and any other pertinent details. The agreement should be executed, signed, and dated by the primary supervising physician and the APP.

Establish written protocols. Define the role of the APP in detail, including the main types of cases that the APP will see and practice guidelines, such as limiting the number of times a patient can see the APP without seeing a physician or specifying the types of injuries, conditions or symptoms that must be examined by a physician.

Document any delegation of authority to the APP. This should include, but not be limited to, prescriptive authority agreements, standing delegation orders, standing medical orders, protocols, or other practice guidelines.

Solicit patient feedback on APPs. Intermittent checks can help alert the physician to any issues that could lower patient satisfaction.

Keep geographic and other limitations in mind. Physicians are sometimes required to supervise APPs at multiple facilities with some distance between them. Work out the details of such arrangements in advance so that you are satisfied that these supervisory obligations can be met.

Maintain accurate documentation. Providers should make an effort to document the specific person completing each portion of care in the record to avoid any confusion.

Be available for questions. In some states, including Texas, a high level of collaboration is expected between physicians and APPs.  Let the APP know that whenever they are in doubt, they should ask questions. An APP should have reliable contact information for the supervising physician.