Perioperative and Anesthetic Adverse events in Thailand (PAAd Thai) incident reporting study: anesthetic profiles and outcomes
, , , , , , , , , , , , , , , e | 31 ago 2017
INFORMAZIONI SU QUESTO ARTICOLO
Article Category: Original article
Pubblicato online: 31 ago 2017
Pagine: 21 - 32
DOI: https://doi.org/10.5372/1905-7415.1101.535
Parole chiave
© 2017 Somrat Charuluxananan, Wimonrat Sriraj, Yodying Punjasawadwong, Siriporn Pitimana-aree, Varinee Lekprasert, Thewarug Werawatganon, Wirat Wasinwong, Prapa Ratanachai, Dujduen Sriramatr, Sunida Atichat, Wanna Angkasuvan, Chuthamat Somchat, Duangporn Tanutanud, Thidarat Ariyanuchitkul, Jaroonpong Choorat, Krairerk Sintavanuruk, Jeratkana Janngam
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.
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Monitoring equipment used during anesthesia in 2,206 incident reports
| Monitoring equipment | n (%) |
|---|---|
| Pulse oximeter | 2188 (99.2) |
| Electrocardiograph | 2180 (98.8) |
| Sphygmomanometer (noninvasive blood pressure) | 2144 (97.2) |
| Capnometer | 1789 (81.8) |
| Spirometer | 1005 (45.6) |
| End tidal gas analyzer | 820 (37.2) |
| Invasive arterial pressure monitor | 531 (24.1) |
| Thermometer | 476 (21.6) |
| Central venous pressure catheter | 402 (18.2) |
| Oxygen analyzer | 391 (17.7) |
| Pulmonary arterial pressure analyzer | 37 (1.7) |
| Echocardiograph | 25 (1.1) |
| Electroencephalograph | 12 (0.5) |
| Cardiac output monitor | 7 (0.3) |
Phase and location of occurrence of incidents (N = 2,206 reports)
| n (%) | |
|---|---|
| Preinduction | 112 (5.1) |
| Induction | 496 (22.5) |
| Maintenance | 761 (34.5) |
| Emergence | 152 (6.9) |
| Recovery | 224 (10.2) |
| Postoperative 24 h | 381 (17.3) |
| Induction room | 15 (0.7) |
| Operating room | 1433 (65.0) |
| Recovery room | 235 (14.6) |
| Intensive care | 167 (7.6) |
| Delivery room | 3 (0.1) |
| Ward | 239 (10.8) |
| Imaging unit | 10 (0.5) |
| During transportation | 14 (0.6) |
| Others (gastrointestinal endoscopy unit, | 6 (0.2) |
Factors contributing to the incidents (N = 2,206 reports)
| Contributing factors | n (%) |
|---|---|
| Noncompliance with surgical safety checklists | 35 (1.6) |
| Inappropriate decision | 307 (13.9) |
| Inadequate knowledge | 125 (5.7) |
| Inexperience | 630 (28.6) |
| Haste | 188 (8.5) |
| Fatigue | 11 (0.5) |
| Inadequate personnel | 24 (1.1) |
| Communication defect | 86 (3.9) |
| Not familiar with environment | 6 (0.3) |
| Emergency condition | 418 (18.9) |
| Inadequate preanesthetic evaluation | 333 (15.1) |
| Inadequate preanesthetic preparation | 116 (5.3) |
| Inadequate equipment | 35 (1.6) |
| Inefficient equipment/monitoring | 55 (2.5) |
| Monitor not available | 8 (0.4) |
| Error in drug label | 29 (1.3) |
| No recovery room | 4 (0.2) |
| Blood bank problems | 21 (1.0) |
Factors minimizing incidents in 2,206 incident reports
| Factors | n (%) |
|---|---|
| Compliance with surgical safety checklists | 105 (4.8) |
| Having experience | 995 (45.1) |
| Experienced assistant | 736 (33.4) |
| Vigilance | 1150 (52.1) |
| Adequate personnel | 32 (1.5) |
| Effective supervision | 129 (5.8) |
| Effective communication | 186 (8.4) |
| Improvement of training | 75 (3.4) |
| Adequate equipment | 83 (3.8) |
| Adequate maintenance | 44 (2.0) |
| Equipment check up | 57 (2.6) |
| Adequate monitoring equipment | 85 (3.9) |
| Comply to practice guidelines | 189 (8.6) |
| Other | 58 (2.6) |
Critical incidents classified by perioperative periods for 2,206 incident reports and overall incidence
| Critical incidents (N = 2,206 reports) | Overall | ||||
|---|---|---|---|---|---|
| Operative period n (%) | Postanesthesia care unit n (%) | Postoperative 24h n (%) | Total (N = 2,206) n (%) | Incidence (95% Cl) per 10,000 | |
| Pulmonary aspiration | 30(1.4) | 1(0.1) | 2(0.1) | 33(11.5) | 1.36(0.89,1.82) |
| Suspected pulmonary embolism | 14(0.6) | 4(0.2) | 1(0.0) | 17(0.8) | 0.51(0.27,0.75) |
| Esophageal intubation | 184(8.3) | – | – | 184(8.3) | 8.51(7.28,9.74) |
| Endobronchial intubation | 24(1.1) | – | – | 24(1.1) | 1.11(0.67,1.55) |
| Oxygen desaturation | 342(15.5) | 119(5.4) | 17(0.8) | 465(21.1) | 13.95 (12.69,15.00) |
| Reintubation | 63 (2.9) | 113(5.1) | 66(3.0) | 240(10.9) | 11.10(9.70,12.51) |
| Difficult intubation | 172(7.8) | 2(0.1) | – | 173 (7.8) | 8.00(6.81,9.19) |
| Failed intubation | 16(0.7) | – | – | 16(0.7) | 0.74(0.38,1.10) |
| Total spinal block | 2(0.1) | – | – | 2(0.1) | 0.32 (–0.12,0.77) |
| Awareness during general anesthesia | – | – | 10(0.5) | 10(0.5) | 0.41(0.16,0.67) |
| Coma/cerebrovascular accident/convulsion | 8(0.4) | 11(0.5) | 39(1.8) | 53 (2.4) | 1.59(1.16,2.02) |
| Nerve injury | 5(0.2) | 1(0.1) | 16(0.7) | 21(1.0) | 0.63(0.36,0.90) |
| Transfusion mismatch | 4(0.2) | 3 (0.2) | – | 7(0.3) | 0.21(0.05,0.37) |
| Suspected myocardial infarction/ischemia | 20(0.9) | 4(0.2) | 14(0.6) | 34(1.5) | 1.02(0.68,1.36) |
| Severe arrhythmia | 467(21.2) | – | – | 467(21.2) | 14.01 (12.74,15.29) |
| Cardiac arrest within 24 h | 255(11.6) | 9(0.4) | 272(12.3) | 519(23.5) | 15.58(14.24,16.91) |
| Death within 24 h | 107(4.9) | 5(0.3) | 330(15.0) | 442(20.0) | 13.26(12.03,14.50) |
| Anaphylaxis/anaphylactoidreaction/allergy | 67(3.0) | 14(0.6) | 1(0.0) | 79(3.6) | 2.37(1.85,2.89) |
| Drug error | 104(4.7) | 1(0.1) | 2(0.1) | 107(4.9) | 3.21(2.60,3.82) |
| Equipment malfunction/failure | 47(2.1) | – | 2(0.1) | 4.7 (2.1) | 1.41(1.01,1.81) |
| Anesthesia personnel hazard | 2(0.1) | 15 (0.7) | – | 17(0.8) | 0.60(0.34,0.97) |
| Suspected emergence delirium | 2(0.1) | 15 (0.7) | – | 17(0.8) | 0.60(0.34,0.97) |
| Wrong patient/site/surgery | 6(0.3) | – | – | 6(0.3) | 0.18(0.04,0.32) |
Immediate and long-term (7-day) outcomes for 2,206 incident reports
| n (%) | |
|---|---|
| Complete recovery | 553 (25.1) |
| Death | 432 (19.6) |
| Major physiological change | 326 (14.8) |
| Respiratory | 207 (9.4) |
| Cardiovascular | 91 (4.1) |
| Neurological | 66 (3.0) |
| Cardiac arrest | 261 (11.8) |
| Unplanned intensive care unit admission | 163 (7.4) |
| Minor physiological change | 72 (3.3) |
| Prolonged emergence | 20 (0.9) |
| Awareness | 7 (0.3) |
| Unplanned hospital admission | 5 (0.2) |
| Other | 79 (3.6) |
| Complete recovery | 265 (12.0) |
| Death | 249 (11.3) |
| Prolonged hospital stay | 144 (5.2) |
| Prolonged ventilator support | 132 (6.0) |
| Disability | 6 (0.3) |
| Vegetative stage | 6 (0.3) |
| Psychic trauma | 2 (0.1) |
| Other | 7 (0.3) |
Operation or operative site of surgery in 2,206 incident reports
| n (%) | |
|---|---|
| General surgery | 690 (31.3) |
| Orthopedic | 267 (13.0) |
| Neurosurgery | 168 (7.6) |
| Cardiac | 148 (6.7) |
| Gynecological | 137 (6.2) |
| Otorhinolaryngological | 127 (5.8) |
| Thoracic | 117 (5.3) |
| Urological | 111 (4.9) |
| Endoscopic | 85 (3.9) |
| C-section | 74 (3.4) |
| Vascular | 71 (3.2) |
| Ophthalmological | 69 (3.1) |
| Plastic | 47 (2.1) |
| Dental | 24 (1.1) |
| Intervention | 24 (1.1) |
| Minimally invasive | 19 (0.9) |
| Diagnostic | 8 (0.4) |
| Electroconvulsive | 2(0.1) |
| Radiotherapy | 2(0.1) |
Suggested corrective strategy for prevention of occurrence of incidents (N = 2,206 reports)
| Factors | n (%) |
|---|---|
| Compliance with surgical safety checklists | 114 (5.2) |
| Compliance with guidelines | 638 (28.9) |
| Additional training | 502 (22.8) |
| More manpower | 87 (3.9) |
| Improvement of supervision | 497 (22.5) |
| Improvement of communication | 209 (9.5) |
| More equipment | 76 (3.4) |
| Equipment maintenance | 59 (2.7) |
| Quality assurance activity | 452 (20.5) |
| Good referral system | 33 (1.5) |
| Other | 38 (1.7) |