| The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of anesthetic equipment failure/malfunction: an analysis of 1996 incident reports. | |
| | |
MedLine Citation:
|
PMID: 19938735 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
|
BACKGROUND: The present study is a part of the multi-centered study of model of anesthesia relating adverse events in Thailand by incident report (The Thai Anesthesia Incident Monitoring Study or Thai AIMS). The objective was to identify the frequency distribution, contributing factors, and factors minimizing incident of equipment failure/malfunction. MATERIAL AND METHOD: As a prospective descriptive research design, anesthesia providers reported the data as soon as the incidents of equipment failure/malfunction occurred. Standardized forms of incident report were then mailed to the center at Chulalongkorn University and three anesthesiologists reviewed the data. RESULTS: Ninety-two cases of equipment failure/malfunction were reported from 51 hospitals across Thailand Between January and June 2007, 92 incidents of equipment failure/malfunction were reported out of 1996 anesthesia-related incidents (4.6%). Failed/malfunctioned equipment included anesthetic circuit (17.4%), anesthesia machine (15.2%), capnography (15.2%), laryngoscope (15.2%), ventilator (12%), pulse oximeter (8.7%), vaporizer (4.3%), endotracheal tube (3.3%), sodalime (3.3%), and electrocardiogram (2.2%). All 16 anesthetic circuit incidents (100%) were detected by clinical signs whereas five incidents (31.3%) were detected firstly by monitors. All 14 laryngoscope malfunction (100%) were detected solely by clinical signs. Only one out of eight (12.5%) of pulse oximeter incidents was detected by clinical signs before the pulse oximeter itself. Three out of four (75%) incidents of vaporizer were detected by clinical signs before monitors. The majority of equipment malfunction was considered as related to anesthetic (69.6%) and system factors (69.6%) and 71.7% of incidents were preventable. Seventy-four incidents (80.4%) were caused by human error and, specifically, rule-based error in three fourths. CONCLUSION: Contributing factors were ineffective equipment, haste, lack of experience, ineffective monitors, and inadequate equipment. Factors minimizing incidents were equipment maintenance, pre-use equipment checking, vigilance, prior experience, and compliance to guidelines. Suggested strategies were quality assurance activity, training, and improvement of supervision. |
| | |
Authors:
|
Chaiyapruk Kusumaphanyo; Somrat Charuluxananan; Dujduen Sriramatr; Aksorn Pulnitiporn; Wimonrat Sriraj |
Related Documents
:
|
16116135 - Evidence of reduced frequency of spinal muscular atrophy type i in the cuban population. 7736335 - A 21 year retrospective study of reports of paresthesia following local anesthetic admi... 18606775 - Epidemiological and clinical observations on patients with dengue in puerto rico: resul... 1463355 - Post kala-azar dermal leishmaniasis: a neglected aspect of kala-azar control programmes. 15701285 - Cerebral edema associated with gliadel wafers: two case studies. 1517065 - Electrocardiographic changes in subarachnoid hemorrhage secondary to cerebral aneurysm.... |
Publication Detail:
|
Type: Journal Article; Multicenter Study; Research Support, Non-U.S. Gov't |
Journal Detail:
|
Title: Journal of the Medical Association of Thailand = Chotmaihet thangphaet Volume: 92 ISSN: 0125-2208 ISO Abbreviation: J Med Assoc Thai Publication Date: 2009 Nov |
Date Detail:
|
Created Date: 2009-11-26 Completed Date: 2010-01-26 Revised Date: - |
Medline Journal Info:
|
Nlm Unique ID: 7507216 Medline TA: J Med Assoc Thai Country: Thailand |
Other Details:
|
Languages: eng Pagination: 1442-9 Citation Subset: IM |
Affiliation:
|
Department of Anesthesiology, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand. |
Export Citation:
|
APA/MLA Format Download EndNote Download BibTex |
| MeSH Terms | |
Descriptor/Qualifier:
|
Anesthesia
/
adverse effects* Anesthesiology / instrumentation* Equipment Failure Analysis / statistics & numerical data* Equipment Safety Humans Medical Errors / statistics & numerical data Prospective Studies Risk Factors Thailand |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
Previous Document: A biomechanical comparison of a tendon repair device and 4 stranded, cruciate repair sutures for fle...
Next Document: N-terminal pro brain natriuretic peptide and cardiac function in doxorubicin administered pediatric ...