Publication: The perioperative and anesthetic adverse events in Thailand (PAAd Thai) study of anesthetic equipment malfunction or failure: An analysis of 2,206 incident reports
22
Issued Date
2021-02-01
Resource Type
ISSN
01252208
Other identifier(s)
2-s2.0-85100886748
Rights
Mahidol University
Rights Holder(s)
SCOPUS
Bibliographic Citation
Journal of the Medical Association of Thailand. Vol.104, No.2 (2021), 286-292
Suggested Citation
Panaratana Ratanasuwan, Wimonrat Sriraj, Yodying Punjasawadwong, Jaroonpong Choorat, Somrat Charuluxananan, Thanist Pravitharangul The perioperative and anesthetic adverse events in Thailand (PAAd Thai) study of anesthetic equipment malfunction or failure: An analysis of 2,206 incident reports. Journal of the Medical Association of Thailand. Vol.104, No.2 (2021), 286-292. doi:10.35755/jmedassocthai.2021.02.11786 Retrieved from: https://repository.li.mahidol.ac.th/handle/123456789/78469
Research Projects
Organizational Units
Authors
Journal Issue
Thesis
Title
The perioperative and anesthetic adverse events in Thailand (PAAd Thai) study of anesthetic equipment malfunction or failure: An analysis of 2,206 incident reports
Abstract
Background: Anesthesia equipment problems may contribute to anesthesia mortality and morbidity. The Royal College of Anesthesiologists of Thailand initiated a multicentered incident reporting study namely the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study to investigate perioperative complications including equipment malfunction or failure. Materials and Methods: The present report was a descriptive prospective study. After the Institutional Ethical approval with informed consent was waived, the case record form comprising structured and narrative information parts was requested to be filled within 24 hours of occurrence of anesthesia equipment malfunction or failure in 22 large government hospitals across Thailand between January and December 2015. Three senior anesthesiologists reviewed the incident reports. Any discrepancy was discussed to achieve a consensus. Descriptive statistics were used for analysis. Results: Out of 2,206 incident reports, there were 47 (2.1%) equipment malfunction or failure involving anesthetic machine (36.0%), anesthetic circuit (27.6%), laryngoscope (17.0%) and monitoring (12.7%) in operating theatre (97.8%), pediatric anesthesia (19.1%), and emergency condition (21.2%). Diagnoses of incidents was either clinical detection (82.9%) or detection by monitoring equipment (48.9%). Outcomes of incidents were trivial with full recovery. The incidents were considered as results from human factor (38.3%), preventable (46.8%), and might be prevented with surgical safety checklists (34.0%). Conclusion: Equipment malfunction or failure incidents were unusual and did not lead to serious consequence. Common contributing factors were ineffective equipment, non-adherence to surgical checklists, haste, and inexperience of performers. Factors to minimize the incidents were equipment checking, having experience, and comply to surgical checklists. Quality assurance activity, standard and regular equipment maintenance, adherence to surgical checklists, and additional training were suggested as corrective measures.