Publication:
Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study): Results

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Issued Date

2008

Resource Type

Article

File Type

application/pdf

ISSN

1252208

Other identifier(s)

2-s2.0-48249121912

Rights Holder(s)

Scopus

Bibliographic Citation

Journal of the Medical Association of Thailand. Vol 91, No.7 (2008), p.1011-1019

Suggested Citation

Charuluxananan S., Suraseranivongse S., Jantorn P., Sriraj W., Chanchayanon T., Tanudsintum S., Kusumaphanyo C., Suratsunya T., Poajanasupawun S., Klanarong S., Pulnitiporn A., Phuping Akavipat M.D., Punjasawadwong Y. 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), p.1011-1019. Retrieved from: https://hdl.handle.net/20.500.14740/3955

Title

Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study): Results

Author(s)

Charuluxananan S.
 Suraseranivongse S.
 Jantorn P.
 Sriraj W.
 Chanchayanon T.
 Tanudsintum S.
 Kusumaphanyo C.
 Suratsunya T.
 Poajanasupawun S.
 Klanarong S.
 Pulnitiporn A.
 Phuping Akavipat M.D.
 Punjasawadwong Y.

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.

Subject(s)

Anesthetic agent
 Adolescent
 Adult
 Aged
 Arterial oxygen saturation
 Article
 Blood pressure
 Capnography
 Child
 Clinical trial
 Consensus
 Death
 Disease course
 Ear nose throat surgery
 Electrocardiogram
 Esophagus intubation
 Female
 Heart arrest
 Heart arrhythmia
 Heart surgery
 Human
 Incident report
 Major clinical study
 Male
 Mean arterial pressure
 Medication error
 Multicenter study
 Neurosurgery
 Operating room
 Patient safety
 Pulse oximeter
 Risk factor
 Thailand
 Unspecified side effect
 Urologic surgery
 Adolescent
 Adult
 Adverse Drug Reaction Reporting Systems
 Aged
 Aged, 80 and over
 Anesthesia
 Child
 Drug Toxicity
 Female
 Humans
 Incidence
 Male
 Middle Aged
 Models, Theoretical
 Patient Care
 Perioperative Care
 Prospective Studies
 Questionnaires
 Registries
 Thailand

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URI

https://hdl.handle.net/20.500.14740/3955

Collections

Scopus: Year 1983-2021

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