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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

หน่วยงาน สถาบันวิจัยและให้คำปรึกษาแห่ง มหาวิทยาลัยธรรมศาสตร์

รายละเอียด

ชื่อเรื่อง : Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study) : results
นักวิจัย : Somrat Charuluxananan , Suwanee Suraseranivongse , Prasatnee Jantorn , Wimonrat Sriraj , Thavat Chanchayanon , Surasak Tanudsintum , Chaiyapruk Kusumaphanyo , Thanarat Suratsunya , Surachart Poajanasupawun , Sireeluck Klanarong , Aksorn Pulnitiporn , Phuping Akavipat , Yodying Punjasawadwong
คำค้น : Adverse events , Anesthesia , Incident report , Incidents , Patient safety
หน่วยงาน : สถาบันวิจัยและให้คำปรึกษาแห่ง มหาวิทยาลัยธรรมศาสตร์
ผู้ร่วมงาน : -
ปีพิมพ์ : 2551
อ้างอิง : Journal of the Medical Association of Thailand. 91,7 (2008) pp. 1011-1019 , 0025-7036 , http://dspace.library.tu.ac.th/handle/3517/803
ที่มา : -
ความเชี่ยวชาญ : -
ความสัมพันธ์ : -
ขอบเขตของเนื้อหา : -
บทคัดย่อ/คำอธิบาย :

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 (1%). 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.

บรรณานุกรม :
Somrat Charuluxananan , Suwanee Suraseranivongse , Prasatnee Jantorn , Wimonrat Sriraj , Thavat Chanchayanon , Surasak Tanudsintum , Chaiyapruk Kusumaphanyo , Thanarat Suratsunya , Surachart Poajanasupawun , Sireeluck Klanarong , Aksorn Pulnitiporn , Phuping Akavipat , Yodying Punjasawadwong . (2551). Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study) : results.
    กรุงเทพมหานคร : สถาบันวิจัยและให้คำปรึกษาแห่ง มหาวิทยาลัยธรรมศาสตร์ .
Somrat Charuluxananan , Suwanee Suraseranivongse , Prasatnee Jantorn , Wimonrat Sriraj , Thavat Chanchayanon , Surasak Tanudsintum , Chaiyapruk Kusumaphanyo , Thanarat Suratsunya , Surachart Poajanasupawun , Sireeluck Klanarong , Aksorn Pulnitiporn , Phuping Akavipat , Yodying Punjasawadwong . 2551. "Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study) : results".
    กรุงเทพมหานคร : สถาบันวิจัยและให้คำปรึกษาแห่ง มหาวิทยาลัยธรรมศาสตร์ .
Somrat Charuluxananan , Suwanee Suraseranivongse , Prasatnee Jantorn , Wimonrat Sriraj , Thavat Chanchayanon , Surasak Tanudsintum , Chaiyapruk Kusumaphanyo , Thanarat Suratsunya , Surachart Poajanasupawun , Sireeluck Klanarong , Aksorn Pulnitiporn , Phuping Akavipat , Yodying Punjasawadwong . "Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study) : results."
    กรุงเทพมหานคร : สถาบันวิจัยและให้คำปรึกษาแห่ง มหาวิทยาลัยธรรมศาสตร์ , 2551. Print.
Somrat Charuluxananan , Suwanee Suraseranivongse , Prasatnee Jantorn , Wimonrat Sriraj , Thavat Chanchayanon , Surasak Tanudsintum , Chaiyapruk Kusumaphanyo , Thanarat Suratsunya , Surachart Poajanasupawun , Sireeluck Klanarong , Aksorn Pulnitiporn , Phuping Akavipat , Yodying Punjasawadwong . Multicentered study of model of anesthesia related adverse events in Thailand by incident report (the Thai anesthesia incidents monitoring study) : results. กรุงเทพมหานคร : สถาบันวิจัยและให้คำปรึกษาแห่ง มหาวิทยาลัยธรรมศาสตร์ ; 2551.