How Your Surgical Team Mitigates Risk

Part of The Joint Replacement Guide — Phase 3: Understanding the Risks · Article 18 of 44 · Hip & Knee

Key Points

  • Joint replacement risks cannot be removed completely, but multiple measures are used before, during and after surgery to reduce them.
  • NHS safety standards incorporate structured checks based on the WHO Surgical Safety Checklist.[2]
  • Infection prevention uses several measures together, including antibiotic prophylaxis, skin preparation, sterile technique and appropriate theatre ventilation.[1,3]
  • Every patient should have a blood-clot and bleeding-risk assessment. The resulting preventive treatment is individualised.[4]
  • Enhanced recovery pathways coordinate preparation, anaesthesia, pain relief, mobilisation and discharge planning.
  • Safety depends on reliable systems, communication and shared responsibility across the whole team.

Safety Is a System

Safe surgery does not depend on one person remembering everything. It uses multiple, overlapping safeguards intended to prevent an error, detect it before harm occurs or allow the team to respond promptly.

These safeguards include:

  • confirming identity, consent, procedure and side;
  • checking allergies and medicines;
  • assessing infection, bleeding and blood-clot risks;
  • checking implants and equipment;
  • antibiotic and blood-loss prevention;
  • monitoring during and after anaesthesia;
  • structured communication between teams; and
  • reviewing outcomes, incidents and near misses.

No system can guarantee that a complication will not occur. The purpose is to make preventable errors less likely and manage unavoidable risks as safely as possible.

The WHO Surgical Safety Checklist

The WHO Surgical Safety Checklist divides the operation into three main stages:

  1. Sign in: before anaesthesia begins.
  2. Time out: immediately before the procedure starts.
  3. Sign out: before the patient leaves the operating theatre.[5]

In NHS-funded care, these principles are incorporated into the National Safety Standards for Invasive Procedures, known as NatSSIPs 2. Local organisations adapt the standards into detailed procedures appropriate for their services.[2]

Checks may include confirming:

  • your identity;
  • the operation and correct side;
  • consent and site marking;
  • allergies;
  • anaesthetic and airway concerns;
  • anticipated blood loss;
  • antibiotic prophylaxis;
  • availability of necessary imaging and equipment;
  • the planned procedure and any particular concerns;
  • instrument, needle and swab counts;
  • specimen labelling; and
  • important instructions for recovery.

The checklist is not intended to replace clinical judgement. Its value comes from creating formal pauses during which the team stops other activity, confirms critical information and gives every member an opportunity to raise a concern.

Early international studies found that introducing the checklist was associated with reductions in complications and deaths.[5,6] Later studies have produced more varied results, showing that merely completing a form is not enough. Its effectiveness depends on meaningful participation, good implementation and a culture in which staff feel able to speak up.[6]

Additional Implant Checks

Joint replacement introduces an additional safety issue: several implant components must be compatible with one another and appropriate for the patient.

NICE recommends two specific intraoperative “stop moments”:

  • one before the components are implanted; and
  • another before the wound is closed.[1]

During these pauses, the team checks implant details and compatibility. NICE also advises considering real-time entry into a system such as the National Joint Registry before implantation, where this can provide an alert about mismatched components.[1]

These checks supplement rather than replace the main surgical safety checklist.

Infection Prevention

Infection prevention relies on a bundle of measures. No single measure eliminates the risk.

Antibiotic prophylaxis

An intravenous antibiotic is normally given before joint replacement. The timing is selected so that an effective concentration is present when the operation begins. If a tourniquet will be used, the antibiotic may need to be given earlier so it has circulated before the tourniquet is inflated.[3]

The antibiotic is selected according to local guidance, allergies, kidney function and relevant infection history. A further dose may be required if the operation lasts longer than the effective duration of the antibiotic.[3]

Prophylactic antibiotics reduce risk but cannot prevent every infection.

Skin preparation and sterile technique

Further measures include:

  • checking the skin around the proposed incision;
  • appropriate preoperative washing instructions;
  • antiseptic preparation of the skin in theatre;
  • sterile gowns, gloves, drapes and instruments;
  • controlled handling of implants;
  • appropriate wound closure and dressings; and
  • hand hygiene and careful wound care after surgery.

Hair should not normally be removed by the patient. If removal is clinically necessary, the team should use an appropriate method rather than a razor, which can damage the skin.[3]

Report cuts, ulcers, rashes, boils or other skin problems near the planned operation before admission.

Theatre ventilation

NICE recommends ultra-clean-air ventilation for primary elective hip, knee and shoulder replacement.[1] These systems are intended to reduce airborne contamination around the surgical field.

The evidence that ultra-clean or laminar airflow directly lowers joint-infection rates is uncertain. NICE acknowledged limitations and conflicting findings but recommended maintaining established UK practice because infection is a serious complication and earlier trial evidence supported the approach.[7]

Ventilation is therefore one part of the infection-prevention system, not a substitute for antibiotic prophylaxis, sterile practice or careful wound care.

Movement within theatre

Unnecessary door opening and movement can disrupt airflow and increase airborne contamination. Theatre teams generally aim to limit avoidable traffic while ensuring that necessary staff, equipment and clinical support remain available.

The relationship between theatre traffic and an individual patient developing infection is difficult to quantify. It is best described as a sensible environmental control rather than a guarantee of prevention.

Preventing Blood Clots

Hip and knee replacement temporarily increase the risk of venous thromboembolism:

  • DVT: a clot in a deep vein, usually in the leg; and
  • PE: a clot that travels to the lungs.

Every patient should have their risks of clotting and bleeding assessed. NICE recommends VTE prophylaxis for elective hip or knee replacement when the risk of VTE outweighs the risk of bleeding.[4]

Depending on that assessment, prevention may include:

  • mobilisation as early as you are safely able;
  • foot and leg exercises;
  • adequate hydration where appropriate;
  • intermittent compression pumps;
  • correctly fitted anti-embolism stockings; and
  • aspirin or an anticoagulant for a specified period.

Not every patient receives every measure. Stockings, compression devices and medicines each have contraindications and practical limitations. The medication and duration also differ between hip and knee replacement and between individuals.

Follow the instructions supplied at discharge. Do not stop blood-thinning medication early or take additional aspirin unless advised.

Reducing Blood Loss

NICE recommends tranexamic acid during primary elective hip or knee replacement unless it is contraindicated. It helps reduce blood loss and the likelihood of transfusion.[1]

Other measures may include:

  • identifying and treating anaemia before surgery;
  • planning the management of anticoagulant medicines;
  • careful surgical control of bleeding;
  • maintaining appropriate body temperature and circulation; and
  • monitoring the blood count after surgery when indicated.

Some blood loss, bruising and swelling remain expected despite these precautions.

Anaesthetic Monitoring

The anaesthetic team monitors you continuously during the operation. Monitoring normally includes:

  • heart rhythm and rate;
  • blood pressure;
  • oxygen level;
  • breathing;
  • temperature; and
  • the effect of anaesthetic medicines.

Additional monitoring may be used according to your health and the complexity of the procedure.

Before surgery, the team reviews medical conditions, previous anaesthetic experiences, allergies and medicines. The anaesthetic and pain-relief plan is then adapted to your circumstances.

Enhanced Recovery Pathways

Enhanced Recovery After Surgery, or ERAS, is a coordinated approach covering the whole surgical pathway rather than a single treatment.[8]

Depending on the hospital and patient, an enhanced recovery pathway may include:

  • clear preoperative education;
  • assessment and preparation of relevant health conditions;
  • avoiding unnecessarily prolonged fasting;
  • an agreed anaesthetic and pain-relief plan;
  • tranexamic acid;
  • opioid-sparing pain relief;
  • prevention of nausea;
  • appropriate fluid management;
  • early return to food and drink;
  • early mobilisation; and
  • discharge based on functional criteria.

The aim is to support safe recovery and reduce avoidable complications and delays. It should not mean rushing someone home or forcing mobilisation before it is safe.

“Same-day mobilisation” means being offered help to stand or walk on the day of surgery when clinically appropriate. NICE states that rehabilitation should be offered on the day of surgery if possible and no later than 24 hours afterwards.[1]

Similarly, discharge should occur when agreed safety and functional criteria are met—not simply when a target number of hours has passed.

Handover and Communication

Information is transferred at several stages, including:

  • pre-assessment to the surgical and anaesthetic teams;
  • theatre to recovery;
  • recovery to the ward;
  • nursing and therapy teams to the discharge team; and
  • hospital to primary or community care where required.

Structured handovers help ensure that important information—such as allergies, blood loss, pain treatment, wound concerns, mobility restrictions and medication plans—is not lost when responsibility changes.

You and your family can contribute by asking questions, checking that information has been understood and mentioning anything that appears inconsistent. Raising a concern is appropriate and should be welcomed.

Learning From Incidents and Outcomes

Patient-safety incidents and near misses should be recorded and considered through the organisation’s patient-safety systems. The response should be proportionate: not every incident requires the same type of investigation, but the aim is to identify learning and improve systems rather than focus only on individual blame.

At a national level:

  • the National Joint Registry records implant and revision information and monitors surgeon and hospital revision performance;[9]
  • GIRFT uses national data and clinical review to examine variation in orthopaedic care and support improvement;[10] and
  • local and national audits examine infection, readmission, length of stay and other outcomes.

These systems are valuable but have limits. For example, the NJR focuses particularly on implants and revisions and does not capture every complication or every aspect of a patient’s experience. A low revision rate is therefore not a complete measure of safety or quality.

If a surgeon or unit appears to have a higher revision rate than expected, the NJR uses an accountability process to review the data. An alert is a prompt for investigation and does not, by itself, prove poor practice.[9]

The Patient’s Role

You are not responsible for running the safety system, but you can help by:

  • confirming your identity and the planned operation when asked;
  • reporting allergies and previous medication reactions;
  • providing a complete medication list;
  • following fasting and medicine instructions;
  • reporting new illness, infection or skin problems;
  • asking if something seems inconsistent;
  • following wound-care and blood-clot prevention instructions; and
  • knowing how to contact the team after discharge.

You should expect some questions to be repeated. Repetition is usually an intentional safety feature rather than evidence that staff have failed to communicate.

The Bottom Line

Safe joint replacement depends on multiple measures working together: preparation, checklists, implant verification, infection prevention, blood-loss and clot prevention, monitoring, early recovery support and effective communication.

These systems reduce risk but cannot remove it. You should still receive an individual discussion of the potential benefits, material risks and reasonable alternatives before deciding whether to proceed.

This article provides general information and does not replace advice from your own clinical team. Local safety procedures and enhanced recovery pathways vary between hospitals.

References

  1. National Institute for Health and Care Excellence. Joint replacement (primary): hip, knee and shoulder. NICE guideline NG157. London: NICE; 2020. Sections 1.4–1.6 and 1.10. Available from: https://www.nice.org.uk/guidance/ng157/chapter/Recommendations
  2. NHS England. National Safety Standards for Invasive Procedures: NatSSIPs 2. London: NHS England; 2023. Available from: https://www.england.nhs.uk/patient-safety/natssips/
  3. National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. NICE guideline NG125. London: NICE; 2019, updated 2020. Available from: https://www.nice.org.uk/guidance/ng125/chapter/Recommendations
  4. National Institute for Health and Care Excellence. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep-vein thrombosis or pulmonary embolism. NICE guideline NG89. London: NICE; 2018, updated 2019. Recommendations 1.11.5–1.11.10. Available from: https://www.nice.org.uk/guidance/ng89/chapter/Recommendations
  5. World Health Organization. WHO Surgical Safety Checklist and implementation manual. Geneva: WHO; 2009. Available from: https://qualityhealthservices.who.int/quality-toolkit/qt-catalog-item/implementation-manual-who-surgical-safety-checklist-2009-safe-surgery-saves-lives
  6. World Health Organization. Global patient safety report 2024. Geneva: WHO; 2024. Available from: https://www.who.int/publications/i/item/9789240095458
  7. National Institute for Health and Care Excellence. Evidence review for ultra-clean air: joint replacement. Evidence review I supporting NICE guideline NG157. London: NICE; 2020. Available from: https://www.nice.org.uk/guidance/ng157/evidence/i-ultraclean-air-pdf-315756469332
  8. Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery Society recommendations. Acta Orthop. 2020;91(1):3–19. doi:10.1080/17453674.2019.1683790. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7006728/
  9. National Joint Registry. NJR Accountability and Transparency Model. Available from: https://www.njrcentre.org.uk/about-the-njr/njr-accountability-and-transparency/
  10. Getting It Right First Time. Orthopaedic surgery. Available from: https://gettingitrightfirsttime.co.uk/surgical_specialties/orthopaedic-surgery/

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