title: Study of model of anesthesia related adverse event by incident report at King Chulalongkorn Memorial Hospital.
abstract: OBJECTIVE
  As a site of the Thai Anesthesia Incidents Monitoring Study (Thai AIMS), the authors continued data collection of incident reports to find out the frequency, clinical course, contributing factors, factors minimizing adverse events, and investigation of model appropriate for possible corrective strategies in a Thai university hospital.
  
  
  METHODS
  A standardized anesthesia incident report form that included close-end and open-end questions was provided to the attending anesthesia personnel of King Chulalongkorn Memorial Hospital between January I and December 31, 2007. They filled it on a voluntary and anonymous basis. Each incident report was reviewed by three reviewers. Any disagreement was discussed to achieve a consensus.
  
  
  RESULTS
  One hundred sixty three incident reports were filled reporting 191 incidents. There were fewer male (44%) than female (56%) patients and they had an ASA physical status classification 1 (41%), 2 (43%), 3 (10%), 4 (4%) and 5 (2%). Surgical specialties that posed high risk of incidents were general, orthopedic, gynecological, otorhino-laryngological and urological surgery. Locations of incident were operating room (85%), ward (8%) and recovery room (2%). The common adverse incidents were oxygen desaturation (23%), arrhythmia needing treatment (14%), equipment malfunction (13%), drug error (9%), difficult intubation (6%), esophageal intubation (5%), cardiac arrest (5%), reintubation (4%), and endobronchial intubation (4%). Adverse events were detected by monitoring only (27%), by monitoring before clinical diagnosis (26%), by clinical diagnosis before monitoring (21%), and by clinical diagnosis only (26%). Incidents were considered to be from anesthesia related factor (73%), system factor (16%) and preventable (47%).
  
  
  CONCLUSIONS
  Common factors related to incident were inexperience, lack of vigilance, haste, inappropriate decision, not comply with guidelines, and lack of equipment maintenance. Suggested corrective strategies were quality assurance activity, additional training, clinical practice guidelines, equipment maintenance, and improvement of supervision.
authors.affiliation: Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
authors.forename: Arunchai
authors.initials: A
authors.lastname: Narasethkamol
authors.forename: Somrat
authors.initials: S
authors.lastname: Charuluxananan
authors.forename: Oranuch
authors.initials: O
authors.lastname: Kyokong
authors.forename: Porntep
authors.initials: P
authors.lastname: Premsamran
authors.forename: Sarawut
authors.initials: S
authors.lastname: Kundej
mesh_terms: D000293:Adolescent; D000328:Adult; D016907:Adverse Drug Reaction Reporting Systems; D000368:Aged; D000369:Aged, 80 and over; D000758:Anesthesia / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D003625:Data Collection; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D005791:Patient Care; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D011795:Surveys and Questionnaires; D013785:Thailand; D055815:Young Adult