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15 articles tagged patient safety
The Coroner's Inquest: A Surgeon's Guide to Giving Evidence
An inquest is not a trial and cannot find you liable. It can still be the most exposing day of your career — and the surgeons who find it hardest are the ones who prepared for the wrong thing.
OrthoVellum
coroner / inquest
Safeguarding: Children and Vulnerable Adults in Orthopaedics
You do not need to be certain, and you are not the investigator. Orthopaedics sees safeguarding concerns earlier than almost any other specialty — and the threshold for acting is lower than most surgeons assume.
OrthoVellum
safeguarding / child protection
Incident Reporting: What Happens After You Submit
Surgeons report far less than any other staff group, largely because nothing visibly happens afterwards. Here is where a report actually goes, and what makes one worth reading.
OrthoVellum
patient safety / incident reporting
Never Events: Wrong Site, Wrong Implant, Retained Items
Wrong site surgery is the single most common never event, and orthopaedics owns a disproportionate share of the wrong-implant category. Why they still happen, and what actually prevents them.
OrthoVellum
patient safety / never events
Root Cause Analysis After a Serious Incident
There is rarely a single root cause, and England has now moved away from mandating RCA altogether. What replaced it, how systems analysis actually works, and why hindsight bias ruins most investigations.
OrthoVellum
patient safety / human factors
Duty of Candour: What It Requires and How to Do It Well
Being open after harm is both a professional obligation and, above a threshold, a statutory one. The rules are clearer than most surgeons think — and the instinct to wait until you know more is the wrong one.
OrthoVellum
duty of candour / medico-legal
Running an M&M Meeting That Changes Something
Most morbidity and mortality meetings are a list of cases followed by a shrug. The ones that work share a structure, a classification, and an actions register that gets read out first.
OrthoVellum
clinical governance / patient safety
Capacity and Best-Interests Decisions in Orthopaedic Practice
Capacity is decision-specific, time-specific, and presumed until disproved. The commonest error in surgical practice is treating a refusal you disagree with as evidence of incapacity.
OrthoVellum
capacity / consent
PDSA Cycles That Actually Finish
Most surgical improvement projects die between the first measurement and the second. The reasons are predictable — and so are the fixes.
OrthoVellum
quality improvement / audit
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