The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of Desaturation: An Analysis of 1,996 Incident Reports
Sirilak Suksompong MD*, Sunisa Chatmongkolchat MD**, Thanoo Hintong MD***, Sireeluck Klanarong MD****, Waraporn Cha-in MD*****, Tanit Virankabutra MD******
Affiliation : * Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok ** Department of Anesthesiology, Songklanagarind Hospital, Prince of Songkla University, Songkhla *** Department of Anesthesiology, Chiang Mai University, Chiang Mai **** Department of Anesthesiology, Buddhachinaraj Regional Hospital, Phitsanulok ***** Department of Anesthesiology, Srinakarind Hospital, Khon Kaen University, Khon Kaen ****** Department of Anesthesiology, Ramathibodi Hospital, Mahidol University, Bangkok
Background and Rationale: The present study is a part of the Multicentered Study of Model of Anesthesia
related Adverse Events in Thailand by Incident Report (The Thai Anesthesia Incident Monitoring Study
or Thai AIMS). The objective of the present study was to determine the frequency distribution, outcomes,
contributory factors, and factors minimizing incident.
Material and Method: The present study is a prospective descriptive research design. The authors extracted
relevant data from the incident reports on oxygen desaturation from the Thai AIMS database and analyzed
during the study period between January and June 2007.
Results : From the relevant 445 incidents, most of the incidents (89%) occurred in patients receiving general
anesthesia. The incidence in patients receiving regional anesthesia was 4.0%. The events mostly occurred in
patients aged between 16-65 years (52.8%). Most of the events (76%) took place in the operating theater
during the induction period (30.1%). More than 81% of the patients experienced severe oxygen desaturation
(SpO2 < 85%). There were 55 patients (12.4%) who had unplanned ICU admission and 2 patients (0.4%) who
had unplanned hospital admission. Factors that may relate to the incident involve combined factors (50.8%).
Anesthetic factors were found to involve 38.4% of incidents. The common contributing factors that might lead
to the incidents were inexperienced (57.5%), inappropriate decision (56.2%), and haste (23.8%). For factors
minimizing incident, the important factors were vigilance (86.3%), experienced in that tropic (71.2%), and
experienced assistance (54.8%). Quality assurance activity was the most common suggestive corrective
strategy (79.1%). The others were improvement of supervision (47.2%) and guideline practice (46.5%).
Conclusion : To lower the incidence of oxygen desaturation, the anesthesia personnel has to improve the
anesthesia services by quality assurance activity, improvement of supervision, clinical practice guidelines,
and additional training.
Keywords : Oxygen desaturation, Hypoxemia, Pulse oximeter, Incident, Complications
