Recovery room incidents from the first 2,000 reports: Perioperative and anesthetic adverse events in Thailand [PAAd thai] study

Abstract

© 2018, Medical Association of Thailand. All rights reserved. Background: The Royal College of Anesthesiologists hosted the Perioperative and Anesthetic Adverse Events in Thailand [PAAd Thai] Study to investigate incidences and models of anesthesia related adverse events for suggested preventive strategies. Objective: To investigate critical incidents occurring in the Post Anesthesia Care Unit [PACU]. Materials and Methods: Structured incident reports were requested to be filled in by anesthesia provider and/or site manager of 22 hospitals in Thailand. Critical incidents of interest occurred in the PACU between January 1 and December 31, 2015 and were sent for review by three senior anesthesiologists. Discussion and consensus was used to resolve any discrimination among reviewers. Descriptive statistics were used. Results: Among 333,219 anesthetics, there were 221 incidents (10.5%) of the first 2,000 incident reports that occurred in the PACU. The most common critical incidents were respiratory complications (81%) such as reintubation (50.7%), oxygen desaturation (50.2%), suspected emergence delirium (6.6%), and anaphylaxis/anaphylactoid or allergic reaction (5.7%). Four cardiac arrests occurred with two deaths within 24 hours. Conclusion: Twenty percent of the incidents were considered preventable. Regarding the model of anesthesia related adverse events, the contributing factors were inappropriate decision making, inadequate preanesthetic evaluation, and inexperience. The factors minimizing incidents were vigilance and having experience. Suggested corrective strategies are quality assurance activities, training, improvement of supervision, and communication. A handoff procedure using checklists was suggested for further improvement.