The Perioperative and Anesthetic Adverse Events in
Thailand (PAAd Thai) Study of Anesthetic Equipment
Malfunction or Failure: An Analysis of 2,206 Incident
Reports
Panaratana Ratanasuwan MD¹, Wimonrat Sriraj MD¹, Yodying Punjasawadwong MD², Jaroonpong Choorat MD³,
Somrat Charuluxananan MD⁴, Thanist Pravitharangul MD⁵
Affiliation :
¹ Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand ² Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand ³ Department of Anesthesiology, Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand ⁴ Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ⁵ Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
Background : Anesthesia equipment problems may contribute to anesthesia mortality and morbidity. The Royal College of Anesthesiologists of
Thailand initiated a multicentered incident reporting study namely the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai)
Study to investigate perioperative complications including equipment malfunction or failure.
Materials and Methods : The present report was a descriptive prospective study. After the Institutional Ethical approval with informed consent was waived, the case record form comprising structured and narrative information parts was requested to be filled within 24 hours of occurrence of anesthesia equipment malfunction or failure in 22 large government hospitals across Thailand between January and December 2015. Three senior anesthesiologists reviewed the incident reports. Any discrepancy was discussed to achieve a consensus. Descriptive statistics were used for analysis.
Results : Out of 2,206 incident reports, there were 47 (2.1%) equipment malfunction or failure involving anesthetic machine (36.0%), anesthetic circuit (27.6%), laryngoscope (17.0%) and monitoring (12.7%) in operating theatre (97.8%), pediatric anesthesia (19.1%), and emergency condition (21.2%). Diagnoses of incidents was either clinical detection (82.9%) or detection by monitoring equipment (48.9%). Outcomes of incidents were trivial with full recovery. The incidents were considered as results from human factor (38.3%), preventable (46.8%), and might be prevented with surgical safety checklists (34.0%).
Conclusion : Equipment malfunction or failure incidents were unusual and did not lead to serious consequence. Common contributing factors were ineffective equipment, non-adherence to surgical checklists, haste, and inexperience of performers. Factors to minimize the incidents were equipment checking, having experience, and comply to surgical checklists. Quality assurance activity, standard and regular equipment maintenance, adherence to surgical checklists, and additional training were suggested as corrective measures.
Received 17 August 2020 | Revised 12 October 2020 | Accepted 12 October 2020
doi.org/10.35755/jmedassocthai.2021.02.11786
Keywords :
Anesthesia, Complications, Equipment malfunction, Equipment failure, Human factors, Surgical checklist
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