Study of Model of Anesthesia Related Adverse Event by Incident Report at King Chulalongkorn Memorial Hospital
Arunchai Narasethkamol MD*, Somrat Charuluxananan MD**, Oranuch Kyokong MD*, Porntep Premsamran MD***, Sarawut Kundej MD***
Affiliation : * Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ** Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University and Chulalongkorn Research Center for Quality, Safety and Innovation in Patient Care, Bangkok, Thailand *** Department of Anesthesiology, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
Objective : As a site of the Thai Anesthesia Incidents Monitoring Study (Thai AIMS), the authors continued data collection of
incident reports to find out the frequency, clinical course, contributing factors, factors minimizing adverse events, and
investigation of model appropriate for possible corrective strategies in a Thai university hospital.
Material and Method: A standardized anesthesia incident report form that included close-end and open-end questions was
provided to the attending anesthesia personnel of King Chulalongkorn Memorial Hospital between January 1 and December
31, 2007. They filled it on a voluntary and anonymous basis. Each incident report was reviewed by three reviewers. Any
disagreement was discussed to achieve a consensus.
Results : One hundred sixty three incident reports were filled reporting 191 incidents. There were fewer male (44%) than
female (56%) patients and they had an ASA physical status classification 1 (41%), 2 (43%), 3 (10%), 4 (4%) and 5 (2%).
Surgical specialties that posed high risk of incidents were general, orthopedic, gynecological, otorhino-laryngological and
urological surgery. Locations of incident were operating room (85%), ward (8%) and recovery room (2%). The common
adverse incidents were oxygen desaturation (23%), arrhythmia needing treatment (14%), equipment malfunction (13%),
drug error (9%), difficult intubation (6%), esophageal intubation (5%), cardiac arrest (5%), reintubation (4%), and
endobronchial intubation (4%). Adverse events were detected by monitoring only (27%), by monitoring before clinical
diagnosis (26%), by clinical diagnosis before monitoring (21%), and by clinical diagnosis only (26%). Incidents were
considered to be from anesthesia related factor (73%), system factor (16%) and preventable (47%).
Conclusion : Common factors related to incident were inexperience, lack of vigilance, haste, inappropriate decision, not
comply with guidelines, and lack of equipment maintenance. Suggested corrective strategies were quality assurance activity,
additional training, clinical practice guidelines, equipment maintenance, and improvement of supervision.
Keywords : Incident, Adverse event, Patient safety, Complication, Anesthesia
