Risk management involves every aspect of patient care and begins as soon the patient or their representative makes contact with you or your staff. The discussion which follows will concentrate on those areas which are particularly pertinent to surgery.

As referenced earlier, the most important aspect of risk management is the rapport which you and your office establish with the patient and family. If they feel you are competent and are doing the very best you can to help them, they are less likely to seek legal redress in case things do not go well. You’re being honest & sympathetic upfront and throughout the experience will go a long way towards gaining their confidence. This entire process again revolves around the Golden Rule, no doubt the best moral guide ever conceived and which has been expressed in multiple ways and multiple times throughout history.

The subtleties and nuances involved in the physician-patient relationship have filled volumes. Acquiring competence in this discipline is an ongoing learning process. Acumen accessing the patient’s and family’s emotional makeup and stability is an appreciable aid in fine-tuning your interactions.

Risk management concerns in surgery can be compartmentalized roughly into preoperative, intraoperative (in the emergency room) and postoperative categories. Chapter 1 covered concerns of the patient and family preoperatively.

When discussing the risks involved in the proposed surgery, I point out that almost every activity in daily living entails some hazard, such as crossing the street, going up and down steps, driving, athletics, etc. Most of the trauma patients requiring repair in the OR have been engaging in high-risk activities, such as driving without a seatbelt, driving intoxicated, in altercations, rock-climbing, etc., at the time they were injured. After enumerating the possible complications entailed in the planned procedure, I often emphasize that the surgical risk is significantly less than that which was associated with the activity they were engaged in when the problem occurred. This observation almost routinely has produced a smile of acknowledgment on the part of the patient and family members and put the comparative hazards in proper perspective.

When preparing for an operation which you do not do routinely, it is important to review the procedure and pertinent anatomy the night before. Go over the possible pitfalls in your mind and how to avoid them and also how to recover in case that should occur. Also have one or more alternate plans if your original approach proves untenable.

In the operating room, operative risk management considerations began with the “time out” routine prior to the initiation of any incision. Marking all of the appropriate sites is crucial. The same marking should be carried out even if the procedure is being done in the office. Some skin lesions are difficult to identify following prepping and injection of local anesthesia.

As will be stressed again later, when prepping about the face avoid using solutions which might damage the eye. Also, prep the entire face and anterior neck and drape out same. Under local anesthesia, such draping is more comfortable for the patient and greatly decreases the risk of fire hazard under general anesthesia.

Never have any solution on the Mayo which cannot be injected into the soft tissues or dropped in the eye. All sorts of noxious solutions have been accidentally injected, such as alcohol, mineral oil and even formaldehyde, because this rule was violated. If you are using a topical anesthetic, pass it off to the circulating nurse immediately after use. If you need mineral oil to take a skin graft, request it immediately prior to use and hand it off as soon as you no longer need it. Unless you observed the scrub, nurse or technician draw up the solution you are about to inject, verify what the solution is with the nurse or technician prior to injection.

When injecting local anesthesia into awake patients steady the involved area with your nondominant hand. This precaution is especially important when injecting about the eye when you’re non--dominant hand should be holding the opposite side of the head.

Never pass sharp instruments over the face. When sponging about the eye always use a wet sponge. A wet sponge is much less likely to cause a corneal abrasion if the cornea is accidentally touched. When operating about the face, always keep in mind that the biggest catastrophe which can occur is damage to an eye. In cases involving increased risk of corneal abrasion such as coronal incisions or open reduction of zygomatic fractures, do temporary tarsorraphies.

When using a dermatome, always check the depth and width adjustments immediately prior to applying the dermatome to the donor area. This step is particularly important when harvesting multiple grafts.

When applying circular dressings about the head or an extremity, be certain the dressings are not too tight. If the head dressing covers the ears, careful padding about the ears is a must.

Skin grafts should be stored intraoperatively in a saline saturated sponge and not in saline to avoid dialysis of the grafts.

The loss of specimens can be minimized by supervising their handling and labeling, being certain that separate specimens are put in separate containers and that the margins have been appropriately identified.

Applying gentle pressure to wounds, particularly those of the scalp and breasts, during extubation can decrease bleeding seen due to increased systolic and venous pressure involved with the extubation. Application of pressure at this time is particularly important if the patient has demonstrated a prolonged bleeding time.

Explain to the patient and family that most wounds show maximal swelling and discoloration in about 36 to 48 hours and that some swelling and discoloration is normal. If the patient has a prolonged bleeding time, the swelling and discoloration will be more marked. By advising patients in advance of the likelihood of these developments, you can avoid phone calls describing anticipated events.

Always carefully document, either in the chart or in the operative note, the nature of the wound or wounds, your repair and instructions regarding wound care, medications and the time of the first office visit. Also stress that if the patient or family is concerned about how things are going, they should contact you. Provide them with your card which includes your home phone number. Remember that if a dispute arises later as to what was said or done, it will be the written or dictated record which will be referenced rather than your recall. Documentation should be particularly thorough in complicated cases, and instances where the defect was such that the outcome will not be optimal or when the patient and/or family are not particularly cooperative.

If a problem occurs postoperatively, such as the partial loss of a flap or graft, wound infection or dehiscence, see the patient frequently in the office. Let the patient and family know that you are as concerned about the complication as they are and that you are doing everything in your power to bring about a satisfactory result.

Advise loosening or removing any dressing which the patient believes may be too tight.

When a split thickness graft has been utilized, it is prudent to see the patient by the second postoperative day. In spite of thorough instructions regarding management of the donor site, patients are frequently confused how to do the dressing.

Also, in instances where elevation of the wound is critical, an early postoperative visit will reinforce compliance in this regard. Your assessment of the patient’s degree of comprehension of the postoperative instructions also is a significant factor in choosing the timing of the initial follow-up visit. When it comes to the timing of this visit, one size definitely does not fit all.

A word concerning your staff. Their interactions with patients should represent the best as far as cordiality, courtesy and the desire to be of service. In my experience, personnel of some physicians’ offices have been rather officious, and have projected an uncaring attitude.