The Thai Anesthesia Incidents Study (THAI Study) of Anesthetic Equipment Failure/Malfunction: A Qualitative analysis for risk factors
Sireeluck Klanarong MD*, Waraporn Chau-in MD **, Aksorn Pulnitiporn MD***, Wiroj Pengpol MD****
Affiliation : Department of Anesthesiology, *Buddhachinaraj Hospital,**Faculty of Medicine, Khon Kaen University, ***Khon Kaen Regional Hospital, ****Ratchaburi Regional Hospital, Thailand
Background : Anesthesia equipment problems may contribute to anesthetic morbidity and mortality. In
Thailand, the magnitude and pattern of these problems has not been established. We therefore analyzed the
frequency, type and severity of equipment-related problems, and what additional efforts might be needed to
improve safety.
Materials and Methods : The data were drawn from the Thai Anesthesia Incidents Study (THAI Study) between
February 1, 2003 and July 31, 2004 in which anesthesia-related data (i.e. of perioperative problems and their
severity) were recorded (by the attending anesthesiologist) from all anesthetic cases on a routine basis. We
selected cases under general and regional anesthesia with anesthetic equipment failure/malfunction for
descriptive analysis.
Results : The frequency of anesthetic equipment problems of the 202,699 recorded cases was approximated
0.04% or 1 : 2252. Two-thirds of the problems (63%) involved the anesthesia machine and of these incidents
73 and 41 percent involved system and human errors, respectively. One patient died and one suffered permanent
morbidity.
Conclusion : The incidence and severity of equipment problems was low. Aside from improvements to
pre-operative equipment checks, vigilance, continuous quality improvement and quality assurance activities
were suggested as strategies to reduce problems.
Keywords : Anesthesia, Complications, Equipment problems, Quality improvement
