Publication: Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study): Results
Issued Date
2008-07-01
Resource Type
ISSN
01252208
01252208
01252208
Other identifier(s)
2-s2.0-48249121912
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Mahidol University
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SCOPUS
Bibliographic Citation
Journal of the Medical Association of Thailand. Vol.91, No.7 (2008), 1011-1019
Suggested Citation
Somrat Charuluxananan, Suwanee Suraseranivongse, Prasatnee Jantorn, Wimonrat Sriraj, Thavat Chanchayanon, Surasak Tanudsintum, Chaiyapruk Kusumaphanyo, Thanarat Suratsunya, Surachart Poajanasupawun, Sireeluck Klanarong, Aksorn Pulnitiporn, M. D. Phuping Akavipat, Yodying Punjasawadwong Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study): Results. Journal of the Medical Association of Thailand. Vol.91, No.7 (2008), 1011-1019. Retrieved from: https://repository.li.mahidol.ac.th/handle/20.500.14594/19634
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Title
Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study): Results
Other Contributor(s)
Chulalongkorn University
Mahidol University
Khon Kaen University
Prince of Songkla University
Phramongkutklao College of Medicine
Srinakharinwirot University
Thammasat University
Naresuan University
Buddhachinaraj Hospital
Khon Kaen Regional Hospital
Thailand Ministry of Public Health
Chiang Mai University
Mahidol University
Khon Kaen University
Prince of Songkla University
Phramongkutklao College of Medicine
Srinakharinwirot University
Thammasat University
Naresuan University
Buddhachinaraj Hospital
Khon Kaen Regional Hospital
Thailand Ministry of Public Health
Chiang Mai University
Abstract
Objective: The Thai Anesthesia Incidents Monitoring Study (Thai AIMS) was aimed to identify and analyze anesthesia incidents in order to find out the frequency distribution, clinical courses, management of incidents, and investigation of model appropriate for possible corrective strategies Material and Method: Fifty-one hospitals (comprising of university, military, regional, general, and district hospitals across Thailand) participated in the present study. Each hospital was invited to report, on an anonymous and voluntary basis, any unintended anesthesia incident during six months (January to June 2007). A standardized incident report form was developed in order to fill in what, where, when, how, and why it happened in both the close-end and open-end questionnaire. Each incident report was reviewed by three reviewers. Any disagreement was discussed and judged to achieve a consensus. Results: Among 1996 incident reports and 2537 incidents, there were more male (55%) than female (45%) patients with ASA PS 1, 2, 3, 4, and 5 = 22%, 36%, 24%, 11%, and 7%, respectively. Surgical specialties that posed high risk of incidents were neurosurgical, otorhino-laryngological, urological, and cardiac surgery. Common places where incidents occurred were operating room (61%), ward (10%), and recovery room (9%). Common occurred incidents were arrhythmia needing treatment (25%), desaturation (24%), death within 24hr (20%), cardiac arrest (14%), reintubation (10%), difficult intubation (8%), esophageal intubation (5%), equipment failure (5%), and drug error (4%) etc. Monitors that first detected incidents were EKG (46%), Pulse oximeter (34%), noninvasive blood pressure (12%), capnometry (4%), and mean arterial pressure (1%). Conclusion: Common factors related to incidents were inexperience, lack of vigilance, inadequate preanesthetic evaluation, inappropriate decision, emergency condition, haste, inadequate supervision, and ineffective communication. Suggested corrective strategies were quality assurance activity, clinical practice guideline, improvement of supervision, additional training, improvement of communication, and an increase in personnel.