Perioperative and Anesthetic Adverse Events in Thailand
(PAAd Thai) Incident Report Study: Anesthetic Adverse
Events in Correlation with Communication Mishaps
Nimmaanrat S, MD, MMed¹, Angkasuvan W, MD², Lapisatepun W, MD³, Charuluxananan S, MD⁴, Choorat J, MD⁵,
Chernsirikasem N, MD⁶, Sriraj W, MD⁷, Pulnitiporn A, MD⁸, Akavipat P, MD⁹
Affiliation : ¹ Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand ² Department of Anesthesiology, Hatyai Hospital, Hat Yai, Songkhla, Thailand ³ Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand ⁴ Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ⁵ Department of Anesthesiology, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand ⁶ Department of Anesthesiology, Phramongkutklao College of Medicine, Bangkok, Thailand ⁷ Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand ⁸ Department of Anesthesiology, Khon Kaen Hospital, Khon Kaen, Thailand ⁹ Department of Anesthesiology, Prasat Neurological Institute, Bangkok, Thailand
Objective: The Royal College of Anesthesiologists of Thailand (RCAT) had performed the trial entitled “The Perioperative Anesthetic
Adverse Events Study in Thailand (PAAd Thai)”. This multi-center, prospective, observational study was held in 22 hospitals all over
the country in 2015. The present trial was a part of the PAAd Thai that explicitly intended to emphasize on anesthetic adverse events
related to communication mishaps.
Materials and Methods: The PAAd Thai working team generated a standardized incident record form. Any incidents marked by reporters by means of either communication problem as a contributing factor, to improve communication as a factor to minimize the incident, or improvement of communication as a suggested corrective strategy were collected for analysis.
Results: Among 2,206 incident reports, there were 234 cases (10.6%) of communication mishaps. The most frequent ineffective communication happened in ASA class III patients. The communication error-related adverse events mainly occurred intraoperatively in cases with cardiac arrest (27.8%), desaturation (23.5%), severe arrhythmia (21.8%), death (17.5%), and re-intubation (15.8%). Unplanned ICU admission accounted for 18.4% of the cases, while 17.5% died. At the seventh day post-operatively, 144 patients fully recovered. Communication problems took place mostly within the anesthesia team (46%) followed by with surgeon (31%). About one tenth happened with more than one type of colleagues.
Conclusion: From PAAd Thai study, communication mishaps were found in approximately 10% of the cases with anesthesia-related adverse events. Effective communication is mandatory for safe anesthesia and surgery. Strategies to improve communication among various health care professionals are highly recommended.
Keywords : PAAd Thai, Adverse events, Communication mishaps, Communication failure, Communication errors, Communication defects,
Ineffective communication
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