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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