The document discusses adverse events related to invasive procedures and surgery. It outlines that adverse events are caused by multiple factors including poor teamwork, safety culture, handoffs, and infection control. The main types of adverse events are infections, complications like sepsis, and failures in communication among healthcare providers. Guidelines, verification processes like surgical checklists, and emphasis on teamwork can help ensure patients receive the correct treatment.

1. Patient safety and invasive
procedures
Merrilyn Walton
Professor of Medical Education(Patient Safety)
Faculty of Medicine
University of Sydney
Australia

2. Adverse event
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3. Learning objective for this session
To understand
-the main causes of adverse events in
surgical and invasive procedural care
-How the use of guidelines, verification
processes, and teamwork can facilitate the
correct patient receiving the correct
treatment at the appropriate time and place.
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4. Knowledge requirements for
nurses/doctors
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5. Multiple Factors associated with adverse events
› Skills and experience of surgical team only 1 factor in Adverse Events
Design of the workplace
Poor teamwork
Poor safety culture
Poor hand over
Poor history taking
Poor continuity of care
Poor infection control
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6. What are the main types of adverse events
experienced in relation to surgery
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7.  Poor infection control methods
 Infections, post operative sepsis
 Inadequate patient management
The main types of adverse events aspoor
infection control methods
inadequate patient management
failure by health-care providers to
communicate effectively before, during and
after operative procedures
with invasive procedural and surgical care
 Cardiovascular complications
 Respiratory complications
 Thromboembolic complications
 Failure by doctors and nurses to communicate effectively before, during
and after operative procedures with each other (the team) and the
patient
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The main types of adverse events associated with
invasive procedural and surgical care

8. Poor infection control
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9. Inadequate patient management
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10. The verification processes for improving
care in invasive procedures
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WHO Surgical Safety Checklist

11. Practise operating room techniques that reduce
risks and errors
Participating in team briefings and
debriefings
Appropriately sharing information
Asking questions
Asserting oneself appropriately
Stating or sharing intentions
Teaching
Managing workload
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12. Surgical mortality and morbidity meetings
o Is the meeting structured?
o Is there an emphasis on education and
understanding?
o Is prevention the goal of the discussion?
o Are these meetings considered a core activity
o Is everyone involved?
o Are nurses, including junior nurses and students,
encouraged to attend?
o How are deaths handled?
o Is a written summary of the discussions kept?
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13. Techniques for safe care
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14. Performance requirements for
nurses/doctors
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15. Summary
 The value of guidelines
 Nurses and doctors need to understand the
reasons for the guidelines
 Verification steps can minimize mistakes
in patient identity
The use if everyday techniques can improve
communication and minimize errors
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