Multicentered study of model of anesthesia related adverse events in Thailand by incident report (The Thai Anesthesia Incidents Monitoring Study): results.
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.


METHODS
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 24 hr (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%).


CONCLUSIONS
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.
Department of Anesthesiology, Chulalongkorn University, Bangkok, Thailand.
Somrat
S
Charuluxananan
Suwanee
S
Suraseranivongse
Prasatnee
P
Jantorn
Wimonrat
W
Sriraj
Thavat
T
Chanchayanon
Surasak
S
Tanudsintum
Chaiyapruk
C
Kusumaphanyo
Thanarat
T
Suratsunya
Surachart
S
Poajanasupawun
Sireeluck
S
Klanarong
Aksorn
A
Pulnitiporn
Phuping
P
Akavipat
Yodying
Y
Punjasawadwong
D000293:Adolescent; D000328:Adult; D016907:Adverse Drug Reaction Reporting Systems; D000368:Aged; D000369:Aged, 80 and over; D000758:Anesthesia / Q000009:adverse effects*; D002648:Child; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D005791:Patient Care; D019990:Perioperative Care; D011446:Prospective Studies; D012042:Registries; D011795:Surveys and Questionnaires; D013785:Thailand