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Topic 10: Patient Safety and Invasive Procedures

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Topic 10: Patient Safety and Invasive Procedures Topic 10: Patient safety and invasive procedures Why patient safety is relevant to Although the principles described in this topic are surgery and invasive procedures 1 important for both surgical and invasive There is now plenty of evidence to show that procedures, most of the evidence in the literature patients who undergo a surgical or an invasive relates to surgical care. procedure are at increased risk of suffering an adverse event [1-3]. This is not because the Learning outcomes: knowledge and surgeons and proceduralists are careless or performance incompetent, rather it is because we now know about the many opportunities for things to go What does a student need to know wrong because of the many steps involved in (knowledge requirements): 3 surgical procedures. In addition, there are the • the main types of adverse events problems caused by surgical site infections that associated with surgical and invasive account for a significant proportion of all health procedures care; care-associated infections. This topic will assist • the verification processes for improving students to understand how patient safety surgical and invasive procedures care. principles can assist in minimizing adverse events associated with invasive procedures. There are What a student needs to do (performance many validated guidelines now available to assist requirements): 4 the health-care team deliver safe surgical care. • follow a verification process to eliminate There may not be many opportunities for students wrong patient, wrong side and wrong to implement many of these steps to improve procedure; surgical outcomes. Nonetheless they can observe • practise operating room techniques that how the health professionals communicate with reduce risks and errors (time-out, briefings, one another and what techniques they use to debriefings, stating concerns); make sure they are operating on the correct person • participate in an educational process for or doing the procedure on the correct body part. reviewing surgical and invasive procedures They can also observe what happens when health- mortality and morbidity. care professionals appear not to follow a protocol. Does this make their job harder or easier? WHAT STUDENTS NEED TO KNOW (KNOWLEDGE REQUIREMENTS) Keywords Surgical and procedural site infections, The main types of adverse events surgical/procedural errors, guidelines, associated with surgical and invasive communication failures, verification processes, procedural care 5 teamwork. The traditional way of explaining adverse events associated with surgery and invasive Learning objective 2 procedures is usually related to the skills of the The objective of this topic is to understand surgeons and the age and physical conditions of the main causes of adverse events in surgical and the patients. Vincent and colleagues [1] believed invasive procedural care and how the use of that adverse surgical (and other procedural) guidelines and verification processes can facilitate outcomes are associated with many other factors the correct patient receiving the correct procedure such as quality of the design-interface, teamwork at the appropriate time and place. and organizational culture. Students should have 216 Topic 10: Patient safety and invasive procedures learnt about a system approach in topic 3 as well there are more adverse events associated with as the topics on teamwork and infection control all surgery when compared to other hospital of which is particularly relevant to this topic. departments. A systems approach to surgical and procedural The main adverse events associated with surgical adverse events requires us to examine both latent care include: factors such as teamwork and inadequate • infections and postoperative sepsis; leadership and sharp end factors such as • cardiovascular complications; communication during handoffs and poor • respiratory complications; history taking. • thromboembolic complications. T3 T4 T9 The three main causes of adverse events in When these events have been analysed, a range surgical care are: T9 (Infection control) of pre-existing conditions (latent factors) have been identified. Some of these are: 1. Poor infection control methods • inadequate implementation of protocols or The Harvard Medical Practice Study II [2] found guidelines; that surgical-wound infections constituted the • poor leadership; second-largest category of adverse events and • poor teamwork; confirmed the long-held belief that hospital-based • conflict between the different departments staphylococcal infections constituted a great risk and the organization; for hospitalized patients, particularly those • inadequate training and preparation of receiving surgical care. The implementation of staff; safer infection control practices such as the • inadequate resources; appropriate administration of prophylactic • lack of evidenced-based practice; antibiotics has reduced postoperative infections. • poor work culture; In addition, increased attention to the risks of • overwork; transmission show health-care workers how they • lack of a system for managing as individuals and members of teams can performance. minimize the risks of cross-infection. In addition to latent factors, individuals working at the sharp end of peri-operative care are prone to Everyone has a responsibility to decrease the the following types of errors known to cause opportunities for contamination of clothing, hands adverse events, including: and equipment that have been associated with • communication failures: transmission routes. Infection control is studied in - information is provided too late to be more detail in topic 9. Students during their effective; training will be present during an operation or - information is inconsistent or inaccurate; invasive procedure. They must at all times comply - key people are excluded from the with the infection control guidelines and practise information; universal precautions. - there are unresolved issues in the team; • failure to take precautions to prevent 2. Inadequate patient management accidental injury; The operating room and environment involves • wound infections, other wound problems, intensely complex activities that may explain why technical problems and bleeding; 217 Topic 10: Patient safety and invasive procedures • avoidable delays in treatment; patient/invasive procedures because it is • failure to take adequate history or physical recognized that one of the best ways to reduce examination; errors caused by misidentification involves • failure to employ indicated tests; implementing best-practice guidelines for • failure to act upon the results of findings ensuring the correct patient receives the correct or tests; treatment. The evidence convincingly • practising outside an area of expertise (failure demonstrates that when health-care professionals to consult, refer, seek assistance, transfer). follow endorsed guidelines and are familiar with the underlying principles supporting a uniform 3. Failure by health-care providers to approach to treating and caring for patients, communicate effectively before, during patient outcomes significantly improve. and after operative procedures. One of the biggest problems in the operating The complexity of the surgical environment is a environment is miscommunication. major factor underpinning communication errors Miscommunication has been responsible for the and they occur at all levels. A study by Lingard and wrong patients having surgery, patients having colleagues [5] described the types of operations on the wrong side or site and having communication failures that are set out in Table 17. the wrong procedure performed. Failure to communicate changes in the patient’s condition For a real example of how errors can occur in and failure to administer prophylactic antibiotics surgical procedures see have also resulted in adverse events. In addition, http://www.gapscenter.va.gov/stories/WillieDesc.asp disagreements about stopping procedures or (accessed January 2009). failing to report errors have been documented. In the Lingard study [5], 36% of communication Health professionals are often required to deal failures resulted in a visible effect such as team with many competing tasks in the operating room. tension, inefficiency, waste of resources and A surgical term is viewed by most trainees and inconvenience to patients or procedural error. students as a very busy term. In addition to high workloads, the peri-operative environment is characterized by staff with varying levels of experience and abilities. This combination of factors can seriously impact on the team’s ability to communicate accurately and timely. Communication problems occur at all stages—but particularly when patients are transferred from one phase of care to another. The extent of adverse surgical events involving wrong site surgery [3] led The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) [4] to include wrong site surgery in its national database of “sentinel events”. Many countries now collect data about wrong 218 Topic 10: Patient safety and invasive procedures Table 17. Types of communication failure with illustrative examples and notes Type of Failure Definition Illustrative example and analytical note (in italics) Occasion Problems in the situation or context The staff surgeon asks the anaesthetist whether the of the communication event antibiotics have been administered. At this point, the procedure has been under way for over an hour. Since antibiotics are optimally given
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