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Original ArticleOpen Access
Study of Model of Anesthesia Related Adverse Event by Incident Report at King Chulalongkorn Memorial Hospital
Charuluxananan S 
,
Narasethkamol A ,
Kyokong O ,
Premsamran P ,
Kundej S
,
Narasethkamol A ,
Kyokong O ,
Premsamran P ,
Kundej S Objective: As a site of the Thai Anesthesia Incidents Monitoring Study (Thai AIMS), the authors continued data collection ofincident reports to find out the frequency, clinical course, contributing factors, factors minimizing adverse events, andinvestigation of model appropriate for possible corrective strategies in a Thai university hospital.
Material and Method: A standardized anesthesia incident report form that included close-end and open-end questions wasprovided to the attending anesthesia personnel of King Chulalongkorn Memorial Hospital between January 1 and December31, 2007. They filled it on a voluntary and anonymous basis. Each incident report was reviewed by three reviewers. Anydisagreement was discussed to achieve a consensus.
Results: One hundred sixty three incident reports were filled reporting 191 incidents. There were fewer male (44%) thanfemale (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 andurological surgery. Locations of incident were operating room (85%), ward (8%) and recovery room (2%). The commonadverse 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%), andendobronchial intubation (4%). Adverse events were detected by monitoring only (27%), by monitoring before clinicaldiagnosis (26%), by clinical diagnosis before monitoring (21%), and by clinical diagnosis only (26%). Incidents wereconsidered to be from anesthesia related factor (73%), system factor (16%) and preventable (47%).
Conclusion: Common factors related to incident were inexperience, lack of vigilance, haste, inappropriate decision, notcomply 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.
Keywords: Incident, Adverse event, Patient safety, Complication, Anesthesia
Material and Method: A standardized anesthesia incident report form that included close-end and open-end questions wasprovided to the attending anesthesia personnel of King Chulalongkorn Memorial Hospital between January 1 and December31, 2007. They filled it on a voluntary and anonymous basis. Each incident report was reviewed by three reviewers. Anydisagreement was discussed to achieve a consensus.
Results: One hundred sixty three incident reports were filled reporting 191 incidents. There were fewer male (44%) thanfemale (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 andurological surgery. Locations of incident were operating room (85%), ward (8%) and recovery room (2%). The commonadverse 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%), andendobronchial intubation (4%). Adverse events were detected by monitoring only (27%), by monitoring before clinicaldiagnosis (26%), by clinical diagnosis before monitoring (21%), and by clinical diagnosis only (26%). Incidents wereconsidered to be from anesthesia related factor (73%), system factor (16%) and preventable (47%).
Conclusion: Common factors related to incident were inexperience, lack of vigilance, haste, inappropriate decision, notcomply 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.
Keywords: Incident, Adverse event, Patient safety, Complication, Anesthesia
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