Recovery Room Incidents from the First 2,000 Reports:
Perioperative and Anesthetic Adverse Events in
Thailand [PAAd Thai] Study
Opas Puchissa MD1, Pin Sriprajittichai MD2, Somrat Charuluxananan MD2, Somchai Viengteerawat MD3,
Prapa Ratanachai MD4, Ampawan Tanyong MD5, Somchai Agprudyakul MD6,
Kwankamol Boonsararuxsapong MD7, Pimwan Sookplung MD8, Phongpat Sattayopas MD9
Affiliation :
1 Department of Anesthesiology, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand
2 Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
3 Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
4 Department of Anesthesiology, Hatyai Hospital, Songkhla, Thailand
5 Department of Anesthesiology, Chonburi Regional Hospital, Chonburi, Thailand
6 Department of Anesthesiology, Buddhasothorn Hospital, Chachoengsao, Thailand
7 Department of Anesthesiology, Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand
8 Department of Anesthesiology, Prasat Heurological Institute, Bangkok, Thailand
9 Department of Anesthesiology, Nakornping Hospital, Chiang Mai, Thailand
Background : The Royal College of Anesthesiologists hosted the Perioperative and Anesthetic Adverse Events in Thailand [PAAd
Thai] Study to investigate incidences and models of anesthesia related adverse events for suggested preventive strategies.
Objective : To investigate critical incidents occurring in the Post Anesthesia Care Unit [PACU].
Materials and Methods : Structured incident reports were requested to be (cid:976)illed in by anesthesia provider and/or site manager of
22 hospitals in Thailand. Critical incidents of interest occurred in the PACU between January 1 and December 31, 2015 and were
sent for review by three senior anesthesiologists. Discussion and consensus was used to resolve any discrimination among reviewers.
Descriptive statistics were used.
Results : Among 333,219 anesthetics, there were 221 incidents (10.5%) of the (cid:976)irst 2,000 incident reports that occurred in the
PACU. The most common critical incidents were respiratory complications (81%) such as reintubation (50.7%), oxygen desaturation
(50.2%), suspected emergence delirium (6.6%), and anaphylaxis/anaphylactoid or allergic reaction (5.7%). Four cardiac arrests
occurred with two deaths within 24 hours.
Conclusion : Twenty percent of the incidents were considered preventable. Regarding the model of anesthesia related adverse
events, the contributing factors were inappropriate decision making, inadequate preanesthetic evaluation, and inexperience. The
factors minimizing incidents were vigilance and having experience. Suggested corrective strategies are quality assurance activities,
training, improvement of supervision, and communication. A handoff procedure using checklists was suggested for further
improvement.
Keywords : Adverse event, Complication, Recovery room, Postanesthesia, Care unit, Quality, Safety
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