Perioperative and anesthetic adverse events in Thailand (PAAd Thai) incident report study: Anesthetic adverse events in correlation with communication mishaps

摘要

? JOURNAL OF THE MEDICAL ASSOCIATION OF THAILAND | 2019. ? JOURNAL OF THE MEDICAL ASSOCIATION OF THAILAND | 2019. Objective: The Royal College of Anesthesiologists of Thailand (RCAT) had performed the trial entitled “The Perioperative Anesthetic Adverse Events Study in Thailand (PAAd Thai)”. This multi-center, prospective, observational study was held in 22 hospitals all over the country in 2015. The present trial was a part of the PAAd Thai that explicitly intended to emphasize on anesthetic adverse events related to communication mishaps. Materials and Methods: The PAAd Thai working team generated a standardized incident record form. Any incidents marked by reporters by means of either communication problem as a contributing factor, to improve communication as a factor to minimize the incident, or improvement of communication as a suggested corrective strategy were collected for analysis. Results: Among 2,206 incident reports, there were 234 cases (10.6%) of communication mishaps. The most frequent ineffective communication happened in ASA class III patients. The communication error-related adverse events mainly occurred intraoperatively in cases with cardiac arrest (27.8%), desaturation (23.5%), severe arrhythmia (21.8%), death (17.5%), and re-intubation (15.8%). Unplanned ICU admission accounted for 18.4% of the cases, while 17.5% died. At the seventh day post-operatively, 144 patients fully recovered. Communication problems took place mostly within the anesthesia team (46%) followed by with surgeon (31%). About one tenth happened with more than one type of colleagues. Conclusion: From PAAd Thai study, communication mishaps were found in approximately 10% of the cases with anesthesia-related adverse events. Effective communication is mandatory for safe anesthesia and surgery. Strategies to improve communication among various health care professionals are highly recommended. Objective: The Royal College of Anesthesiologists of Thailand (RCAT) had performed the trial entitled “The Perioperative Anesthetic Adverse Events Study in Thailand (PAAd Thai)”. This multi-center, prospective, observational study was held in 22 hospitals all over the country in 2015. The present trial was a part of the PAAd Thai that explicitly intended to emphasize on anesthetic adverse events related to communication mishaps. Materials and Methods: The PAAd Thai working team generated a standardized incident record form. Any incidents marked by reporters by means of either communication problem as a contributing factor, to improve communication as a factor to minimize the incident, or improvement of communication as a suggested corrective strategy were collected for analysis. Results: Among 2,206 incident reports, there were 234 cases (10.6%) of communication mishaps. The most frequent ineffective communication happened in ASA class III patients. The communication error-related adverse events mainly occurred intraoperatively in cases with cardiac arrest (27.8%), desaturation (23.5%), severe arrhythmia (21.8%), death (17.5%), and re-intubation (15.8%). Unplanned ICU admission accounted for 18.4% of the cases, while 17.5% died. At the seventh day post-operatively, 144 patients fully recovered. Communication problems took place mostly within the anesthesia team (46%) followed by with surgeon (31%). About one tenth happened with more than one type of colleagues. Conclusion: From PAAd Thai study, communication mishaps were found in approximately 10% of the cases with anesthesia-related adverse events. Effective communication is mandatory for safe anesthesia and surgery. Strategies to improve communication among various health care professionals are highly recommended.