Perioperative anesthetic adverse events in Thailand (Paad Thai): Incident reporting study: An analysis of 69 perioperative adverse events in patients undergoing cesarean section

Abstract

© 2018, Medical Association of Thailand. All rights reserved. Background: The Royal College of Anesthesiologists of Thailand initiated registry and reporting of anesthesia service incidents and outcomes in 2015 [Perioperative Anesthetic Adverse Events in Thailand (PAAd Thai)]. Cesarean section (C-section) was associated with significantly increased risks of anesthesia-related adverse events. All details in these adverse events were important issues to improve maternal safety and outcomes. Objective: To describe the incidents regarding, characteristics and outcomes of anesthetic-related adverse events in the C-section patients in PAAd Thai. Materials and Methods: This study was a multicenter descriptive study of data prospectively collected from 22 hospitals across Thailand between January 1 and December 31, 2015. We extracted relevant data from the incident reports on C-section patients. Three peer reviewers reviewed the completed incident record forms regarding possible mechanisms, contributing factors, appropriate management, and preventive strategies to achieve agreement by a consensus. The data were analyzed by descriptive statistics. Results: Total 2,206 incidents of adverse events were reported from 333,219 cases in primary PAAd Thai. The incidents occurred in 57 parturient patients undergoing cesarean section (C-section).Most of C-section patients were ASA physical status class II (54.5%) and mostly were indicated with emergency reasons (57.1%). The most common anesthetic techniques were general anesthesia (59.6%). The common place and period that the events occurs were intraoperative period (63.16%) (Including induction, intubation, maintenance and emergence) and 28.07% of events were preventable. The three common adverse events included desaturation (17.39%), esophageal intubation (15.94 %) and drug error (14.49 %). Most common immediate and long term outcome were major transient physiologic changes and complete recovery (40.43% and 89.36%, respectively). The most common contributing factor was human factor (75.76%) including inexperience, haste, inadequate knowledge (36.36%, 18.18% and 10.61%, respectively). Improved supervision, quality assurance activity, following guideline practice and additional training could be suggestive corrective strategies to minimizing these adverse events. Conclusion: The authors found that inexperience, haste, and inadequate knowledge were the major contributory factors. Some of them (28%) were preventable and correctable. Supervision, quality assurance, complies to practice guideline and additional training can improve and prevent these serious adverse events, also provide patient safety in the Thai health care system.