The Thai Anesthesia Incidents Study (THAI Study) of anesthetic equipment failure/malfunction: a qualitative analysis for risk factors.
BACKGROUND
Anesthesia equipment problems may contribute to anesthetic morbidity and mortality. In Thailand, the magnitude and pattern of these problems has not been established. We therefore analyzed the frequency, type and severity of equipment-related problems, and what additional efforts might be needed to improve safety.


METHODS
The data were drawn from the Thai Anesthesia Incidents Study (THAI Study) between February 1, 2003 and July 31, 2004 in which anesthesia-related data (i.e. of perioperative problems and their severity) were recorded (by the attending anesthesiologist) from all anesthetic cases on a routine basis. We selected cases under general and regional anesthesia with anesthetic equipment failure/malfunction for descriptive analysis.


RESULTS
The frequency of anesthetic equipment problems of the 202,699 recorded cases was approximated 0.04% or 1 : 2252. Two-thirds of the problems (63%) involved the anesthesia machine and of these incidents 73 and 41 percent involved system and human errors, respectively. One patient died and one suffered permanent morbidity.


CONCLUSIONS
The incidence and severity of equipment problems was low. Aside from improvements to pre-operative equipment checks, vigilance, continuous quality improvement and quality assurance activities were suggested as strategies to reduce problems.
Klanarong
Sireeluck
S
Department of Anesthesia, Bhudhachinaraj Hospital, Phitsanulok, Thailand. ksireeluck@hotmail.com
Chau-in
Waraporn
W
Pulnitiporn
Aksorn
A
Pengpol
Wiroj
W
D000758:Anesthesia / Q000009:adverse effects*; D000776:Anesthesiology / Q000295:instrumentation*; D004868:Equipment Failure / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D010043:Outcome and Process Assessment, Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D013785:Thailand