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

In hopes of uncovering patient safety insights to help medical professionals pursue best practices for risk mitigation, we analyzed 1559 closed medical malpractice claims and suits (814 ambulatory, 745 inpatient) involving orthopedic surgeons from the loss years of 2011 to 2021.

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

As might be expected, the dominant case type represented in our study was improper performance of surgery, weighing in at more than 40 percent of the studied claims. Significantly, 23 percent of the studied claims of this case type resulted in a settlement.

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.

In light of all the challenges, improving communication with patients and families requires access to tools, strategies, and practice. These efforts will be rewarded with reduced risks for litigation. One resource is this guide to Effective Patient Communication: Strategies for Challenging Situations.

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

Risk management in orthopedic surgery inevitably depends on a high degree of technical skill. Still, surgeons who devote their attention to holistic concerns like patient selection and the thorough communication of known risks will be rewarded with risk mitigation.

To learn more, read the study.

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

Founded and led by physicians, The Doctors Company is relentlessly committed to advancing, protecting, and rewarding the practice of good medicine. The Doctors Company helps hospitals and practices of all sizes manage the complexities of today’s healthcare environment—with expert guidance, resources, and coverage—and is the only medical malpractice insurer with an advocacy program covering all 50 states and the federal level. The Doctors Company is part of TDC Group, the nation’s largest physician-owned provider of insurance and risk management solutions. TDC Group serves the full continuum of care.