The Doctors Company conducted a large study to identify trends in orthopedic surgery medical malpractice claims. They found 46 percent of claims allege improper surgery performance, 16 percent allege improper management of the surgical patient and 13 percent are diagnosis related.
Darrell Ranum, JD, vice president of the department of patient safety and risk management at The Doctors Company and Ralph A. Gambardella, MD, chairman and president of Kerlan-Jobe Orthopaedic Clinic in Los Angeles discuss how to provide better patient care and reduce the chance for medicolegal claims.
1. Recognize when complications occur. Patients are at risk during the immediate postoperative period. This is especially true when the patient returns home. Patients must know which symptoms are normal and which are due to a complication and when they need to return to the hospital. “It often falls to the patient to figure out whether there is a crisis that needs to be addressed,” says Mr. Ranum. “Physicians and their staffs need to be sensitive to the concerns of patients who call following a surgical procedure. Sometimes the complications only reveal themselves over time, like nonunions of fractures. But others, like spinal abscess bleeding or compartment syndrome that may cause tissue necrosis or paralysis or hemorrhaging, may require prompt attention. These complications are difficult to diagnose but are a threat.”
2. Strengthen the team. The patient sees many people from the nurses and surgeon’s team to the therapists and other caregivers. Make sure everyone on the team recognizes signs of complications and will alert the surgeon as soon as possible. “If the patient complains of pain, that’s normal, but the nurse has to recognize that if the pain isn’t controlled by medication and increases over time, or if there are vital signs changing, there might be an issue,” says Mr. Ranum. “The internal medicine physician or hospitalist that sees the patient needs to recognize complications for the surgical procedure. Then these complications need to be communicated effectively with the surgeons.”
3. Communication is key. The team must communicate well at all times to prevent complications from spiraling out of control. A surgeon can’t tell the nurse not to bother him or her overnight because a life-threatening issue could compromise the patient’s health. “There is a lot of literature out there showing how effective teamwork can reduce surgical mortality,” says Mr. Ranum.
4. Develop a protocol for patient complaints. Listen to patient complaints and develop a protocol for ensuring those complaints aren’t due to a larger issue. The patient complaint should be elevated at least to the nurse level, says Mr. Ranum, and the frontline staff must know which questions to ask that will differentiate normal post-surgery complaints from complaints associated with larger issues. “Increased temperature, signs of bleeding and swelling are harbingers of complications and the internal process should be strong enough that those inquires of patients aren’t lost in the communication structure,” says Mr. Ranum.
5. Prioritize follow-up calls with patients. Most physicians have patient education programs or materials handed out on what to expect post-surgery, but that information is often overwhelming for patients and their families. A new trend is for nurses to call patients shortly after discharge to follow-up. These calls can identify issues and risks in early stages. “Sometimes patients return home and grit their teeth while their leg is swelling, which is a problem but they don’t think about it,” says Mr. Ranum. “The follow-up calls communicate good will from the surgeon’s practice. They capture information about the patient’s current condition, especially for outpatient procedures, and improve patient compliance with postoperative medication and movement regimens.”
6. Talk to patients, and remind them about earlier conversations when a complication occurs. It’s hard for patients to retain information from preoperative conversations about potential risks and side-effects of the procedure. Mr. Ranum suggests spending as much time as possible with patients making sure they understand those risks. Then, if a complication occurs, relate back to those early conversations. “The patients might not be happy about the complication, but hopefully they will gain a more complete understanding that will prevent them from filing a claim,” he says. “A significant number of patients will go to a different clinician due to dissatisfaction of care, and we don’t know what prompts that, but physician-patient relationships need to be handled with care, which includes helping patients to develop reasonable expectations.”
7. Conduct preoperative screenings for risk assessment. Especially for outpatient surgery, examine the patient’s medical history to prepare for any potential challenges. There is an increased risk for patients with sleep apnea, diabetes or those on blood thinners and knowing these risks can help the medical team prepare for the surgery and react to potential complications more quickly. “In our ASC, we adapted, with the help of anesthesia, a preoperative medical screening process to address problems upfront instead of finding out right before surgery,” says Dr. Gambardella. “We want to make sure patients don’t have a problem afterwards and end up with a claim.”
8. Educate patients before surgery. Patients are responsible for their care and recovery after returning home, and there are certain ways they can lower complication risks. For example, patients who underwent orthopedic surgery shouldn’t fly or drive on long trips for a period after surgery. Dr. Gambardella and his team are piloting a study on an iPhone-friendly app that physicians can customize to guide patients through the recovery period. “The patients get friendly reminders about symptoms, exercises and how to optimize recovery,” he says. “We want to communicate with patients in different ways. People respond differently.Millennials are moving forward in the computer-based world and doing a lot more upfront communication that can impact a large number of these claims.”
A study published in the Journal of Bone and Joint Surgery in June showed an iPhone-based course in anatomy helped produce better outcomes for patients because they had an understanding of their surgery and expectations for outcomes. “I think we are going to have to continue to get the message out there to physicians to embrace these things because it will improve outcomes and reduce claims,” says Dr. Gambardella.
9. Keep up with surgeon education. There are a lot more cadaver courses available now and surgeons don’t have an excuse for poor technique. “Continued training of physicians becomes very important,” says Dr. Gambardella. “Cadaver training and being able to learn a procedure in a cadaver setting is really important. Additionally, using web-based technologies with virtual reality diminishes complications that occur.”
10. Eliminate wrong site issues. Preventable complications such as wrong-site or wrong-side surgery is key from a patient care perspective, and now Medicare will begin penalizing providers for those events. Bundled payments don’t cover preventable complications and providers are more vigilant than ever. “Make sure you’re following the protocol because there shouldn’t be any excuse for wrong-site surgery,” says Dr. Gambardella. “If we can pick a target from 500 miles out from a drone and that’s accurate, we should be able to pick the right level of the spine to operate on.” Monitor the process and make sure everyone is taking the necessary steps to avoid preventable complications.
11. Coordinate with physician extenders. Surgical patients spend time with physicians discussing their procedures and preparing for recovery, but developing a relationship with a physician extender can also help the patients through the process. “We are using physician extenders from a medical standpoint and putting together a team approach that interacts with the surgery personnel to make sure all the ‘T’s are crossed and ‘I’s are dotted,” says Dr. Gambardella. “Physician extenders are important because many people freeze in front of the physician and are afraid to ask a question because they think the question is dumb. But they might ask the physician extender or secretary that question.”