J Med Assoc Thai 2008; 91 (7):1011

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Multicentered Study of Model of Anesthesia Related Adverse Events in Thailand by Incident Report (The Thai Anesthesia Incidents Monitoring Study): Results
Charuluxananan S Mail, Suraseranivongse S , Jantorn P , Sriraj W , Chanchayanon T , Tanudsintum S , Kusumaphanyo C , Suratsunya T , Poajanasupawun S , Klanarong S , Pulnitiporn A , Akavipat P , Punjasawadwong Y

Objective: The Thai Anesthesia Incidents Monitoring Study (Thai AIMS) was aimed to identify and analyze anesthesia
incidents in order to find out the frequency distribution, clinical courses, management of incidents, and investigation of model
appropriate for possible corrective strategies

Material and Method: Fifty-one hospitals (comprising of university, military, regional, general, and district hospitals across
Thailand) participated in the present study. Each hospital was invited to report, on an anonymous and voluntary basis, any
unintended anesthesia incident during six months (January to June 2007). A standardized incident report form was developed
in order to fill in what, where, when, how, and why it happened in both the close-end and open-end questionnaire. Each
incident report was reviewed by three reviewers. Any disagreement was discussed and judged to achieve a consensus.

Results: Among 1996 incident reports and 2537 incidents, there were more male (55%) than female (45%) patients with ASA
PS 1, 2, 3, 4, and 5 = 22%, 36%, 24%, 11%, and 7%, respectively. Surgical specialties that posed high risk of incidents were
neurosurgical, otorhino-laryngological, urological, and cardiac surgery. Common places where incidents occurred were
operating room (61%), ward (10%), and recovery room (9%). Common occurred incidents were arrhythmia needing
treatment (25%), desaturation (24%), death within 24hr (20%), cardiac arrest (14%), reintubation (10%), difficult intubation
(8%), esophageal intubation (5%), equipment failure (5%), and drug error (4%) etc. Monitors that first detected incidents
were EKG (46%), Pulse oximeter (34%), noninvasive blood pressure (12%), capnometry (4%), and mean arterial pressure

Conclusion: Common factors related to incidents were inexperience, lack of vigilance, inadequate preanesthetic evaluation,
inappropriate decision, emergency condition, haste, inadequate supervision, and ineffective communication. Suggested
corrective strategies were quality assurance activity, clinical practice guideline, improvement of supervision, additional
training, improvement of communication, and an increase in personnel.

Keywords: Anesthesia, Adverse events, Incidents, Incident report, Patient safety

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