Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study Database: Neuroanesthesia

2020 ◽  
Vol 103 (7) ◽  
Keyword(s):  
Adverse Events ◽  
Incident Report ◽  
Contributing Factors ◽  
Severe Arrhythmia ◽  
Male Patients ◽  
The Common ◽  
Incident Reports ◽  
Anesthetic Complications ◽  
Age Range ◽  
Study Database

Background: The incident report in neurosurgical anesthesia was part of the Perioperative and Anesthetic Adverse Events in Thailand Study (PAAd Thai) of the Royal College of Anesthesiologists of Thailand in 2015. There were scarce reports of perioperative anesthetic adverse events in neurosurgical cases. Objective: To investigate anesthetic complications and causes, and contributing factors including corrective strategies for the prevention of adverse events in neurosurgical cases. Materials and Methods: A prospective descriptive study was conducted in 22 hospitals across Thailand. Perianesthetic adverse incidents were reported by a standardized incident report form during 12 months period (between January and December 2015). Adverse events of neurosurgical cases were reviewed to demonstrate the causes. Descriptive statistics were used. Results: Among the first 2,000 incident reports from the PAAd Thai study, 228 critical incidents from the 157 incident report forms of neurosurgical cases were reported. The incidents commonly occurred in male patients (56.0%). The major age range was 40 to 70 years. The common adverse events included cardiac arrest within 24 hours (36.3%), death (33.1%), reintubation (15.3%), desaturation (10.8%), severe arrhythmia (10.2%), and difficult intubation (6.4%). Anesthesia was considered as part of the contributing factors in 70 reports while it was considered as the sole factor in 26 reports. Conclusion: Cardiac arrests, death, and reintubation were common incidents in neurosurgical anesthesia. Common factors contributing to the incidents were inexperience, severe increased intracranial pressure, inadequate preanesthetic evaluation, emergency condition, inappropriate decision, and communication. Factors minimizing the incidents were vigilance, having experience, experienced assistant, improvement of training, comply to practice guidelines, and effective communication. Suggested corrective strategies were quality assurance activity, improvement of supervision, additional training, improvement of communication, compliance with guidelines, and more equipment. Keywords: Adverse events, Anesthesia, Multicentered study, Incident report, Neuroanesthesia

The Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study of Endobronchial Intubation: An Analysis of 2,000 Incident Reports

2020 ◽  
Vol 103 (10) ◽  
pp. 1022-1027
Keyword(s):  
Adverse Events ◽  
Incident Report ◽  
Preventive Strategies ◽  
Contributing Factors ◽  
Study Objective ◽  
Endobronchial Intubation ◽  
Anesthesia Service ◽  
Keywords Anesthesia ◽  
Incident Reports ◽  
Voluntary Basis

Background: The Royal College of Anesthesiologists of Thailand hosted a multicentered project, namely the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study. Objective: The aims of the present study were to investigate incidences, contributing factors and suggested preventive strategies of anesthesia-related complications particularly the endobronchial intubation (EBI). Materials and Methods: The PAAd Thai study was a collaborative incident report among 22 hospitals across Thailand. After approval by the Institutional Ethical Committee, the structured incident report together with open ended data record form of anesthesia-related complications such as cardiac arrest, death within 24 hours, and respiratory complications including EBI were requested to be sent to the data management center together with monthly statistics of anesthesia service in each hospital for 12 months (between January 2015 and December 2015) on an anonymous and voluntary basis. The EBI reports were reviewed by three anesthesiologists. Any discretion was discussed to achieve a consensus. Descriptive statistics were used. Results: Among the first 2,000 incident reports, there were 23 EBIs, at the rate of 1.06:10,000 (95% CI 0.62 to 1.49) or 1.15% of all reports. Two-thirds of the incidents occurred in patients with age less than 5 years old and more than 60 years old, and in elective cases. The common sites of surgery were trunk, head and neck, and laparoscopic procedures. EBIs were diagnosed by pulse oximeter (13 cases, 54.0%), increased airway pressure (four cases, 17.2%) and clinical monitoring (four cases 17.2%). Common phases of detection were pre-induction (one case, 4.3%), induction (nine cases, 39.2%), maintenance (12 cases, 52.2%), and emergence (one case, 4.3%). Contributing factors were lack of knowledge, inexperience, and haste, while factors minimizing the incidents were having experience and vigilance. Suggested preventive strategies were additional training, including simulation, practice guidelines, improvement of supervision, and communication. Conclusion: The authors have found that EBI was uncommon, but it is one of the serious anesthesia-related adverse events. It can happen anytime during the entire course of anesthesia. Under these circumstances, careful monitoring and vigilance of the anesthesiologists is essential. Keywords: Anesthesia, Complication, Endobronchial intubation, Intubation, Hypoxia

scholarly journals Profile of Osteomyelitis Patients Visiting the Orthopedic Clinic of Dr. Hasan Sadikin General Hospital, Indonesia, in 2017–2018

2021 ◽  
Vol 8 (1) ◽  
Author(s):  
Aditya Nugraha ◽  
Hermawan Nagar Rasyid ◽  
Hadyana Sukandar
Keyword(s):  
Staphylococcus Aureus ◽  
General Hospital ◽  
Sampling Method ◽  
Operative Procedure ◽  
Bone Destruction ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Male Patients ◽  
The Common ◽  
Age Range

Background: Osteomyelitis is an inflammatory process caused by microorganism infection that leads to bone destruction. Osteomyelitis may affect all bones, particularly long bones, and infects all ages. This disease is hard to diagnose and the treatment is complex due to the disease’s heterogenicity, pathophysiology, clinical presentation, and management. This study aimed to determine the profile of osteomyelitis inpatients and outpatients presented to the Orthopedic Clinic of Dr. Hasan Sadikin General Hospital Bandung, IndonesiaMethods: This was a descriptive cross-sectional study conducted from July to October 2019 using the total sampling method. Data were collected from the medical records of osteomyelitis inpatients and outpatients presented to the Orthopedic Clinic of Dr. Hasan Sadikin General Hospital Bandung, Indonesia from 2017–2018. Data were then analyzed descriptively and the results were presented in frequencies.Result: In total, 90 data were retrieved. Most of data presented male patients (n= 69, 76.7%) with the age range of 20–29 years old (24.4%). The majority of these patients experienced chronic onset of disease (94.4%) located on the tibia (51.1%), which was caused by a post-operative procedure (61.1%). The most common treatment was operative procedure without antibiotic beads (51.1%). Staphylococcus aureus was the common pathogens identified in these patients (22.2%).Conclusion: The majority of osteomyelitis patients are males in productive age with chronic onset of disease located on the tibia caused by a post-operative procedure. Staphylococcus aureus is the common pathogen involved and the most common treatment is an operative procedure without antibiotic beads.

The Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study of Anesthetic Equipment Malfunction or Failure: An Analysis of 2206 Incident Reports

2021 ◽  
Vol 104 (2) ◽  
pp. 286-292
Keyword(s):  
Adverse Events ◽  
Present Report ◽  
Perioperative Complications ◽  
Pediatric Anesthesia ◽  
Contributing Factors ◽  
Case Record ◽  
Mortality And Morbidity ◽  
Surgical Safety ◽  
Anesthesia Equipment ◽  
Incident Reports

Background: Anesthesia equipment problems may contribute to anesthesia mortality and morbidity. The Royal College of Anesthesiologists of Thailand initiated a multicentered incident reporting study namely the Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study to investigate perioperative complications including equipment malfunction or failure. Materials and Methods: The present report was a descriptive prospective study. After the Institutional Ethical approval with informed consent was waived, the case record form comprising structured and narrative information parts was requested to be filled within 24 hours of occurrence of anesthesia equipment malfunction or failure in 22 large government hospitals across Thailand between January and December 2015. Three senior anesthesiologists reviewed the incident reports. Any discrepancy was discussed to achieve a consensus. Descriptive statistics were used for analysis. Results: Out of 2,206 incident reports, there were 47 (2.1%) equipment malfunction or failure involving anesthetic machine (36.0%), anesthetic circuit (27.6%), laryngoscope (17.0%) and monitoring (12.7%) in operating theatre (97.8%), pediatric anesthesia (19.1%), and emergency condition (21.2%). Diagnoses of incidents was either clinical detection (82.9%) or detection by monitoring equipment (48.9%). Outcomes of incidents were trivial with full recovery. The incidents were considered as results from human factor (38.3%), preventable (46.8%), and might be prevented with surgical safety checklists (34.0%). Conclusion: Equipment malfunction or failure incidents were unusual and did not lead to serious consequence. Common contributing factors were ineffective equipment, non-adherence to surgical checklists, haste, and inexperience of performers. Factors to minimize the incidents were equipment checking, having experience, and comply to surgical checklists. Quality assurance activity, standard and regular equipment maintenance, adherence to surgical checklists, and additional training were suggested as corrective measures. Keywords: Anesthesia, Complications, Equipment malfunction, Equipment failure, Human factors, Surgical checklist

Perioperative anaesthetic adverse events in Thailand (PAAd THAI) study: Incident report of perioperative convulsion

2018 ◽  
Vol 28 (6) ◽  
pp. 152-158
Author(s):  
Jatuporn Eiamcharoenwit ◽  
Phuping Akavipat ◽  
Thidarat Ariyanuchitkul ◽  
Nichawan Wirachpisit ◽  
Aksorn Pulnitiporn ◽  
...  
Keyword(s):  
Adverse Events ◽  
Data Management ◽  
Descriptive Statistics ◽  
Incident Report ◽  
Multi Centre Study ◽  
Centre Study ◽  
Incident Reports ◽  
Site Manager ◽  
Safe Anaesthesia ◽  
Relevant Factors

The aim of this study was to identify the characteristics of perioperative convulsion and to suggest possible correcting strategies. The multi-centre study was conducted prospectively in 22 hospitals across Thailand in 2015. The occurrences of perioperative adverse events were collected. The data was collated by site manager and forwarded to the data management unit. All perioperative convulsion incidences were enrolled and analysed. The consensus was documented for the relevant factors and the corrective strategies. Descriptive statistics were used. From 2,000 incident reports, perioperative convulsions were found in 16 patients. Six episodes (37.5%) were related to anaesthesia, 31.3% to patients, 18.8% to surgery, and 12.5% to systemic processes. The contributing factor was an inexperienced anaesthesia performer (25%), while the corrective strategy was improvements to supervision (43.8%). Incidents of perioperative convulsion were found to be higher than during the last decade. The initiation and maintenance of safe anaesthesia should be continued.

Cardiac Arrest and Complications after Spinal Anesthesia: The Perioperative and Anesthetic Adverse Event in Thailand (PAAd Thai) Incident Report Study

2021 ◽  
Vol 104 (4) ◽  
pp. 663-671
Keyword(s):  
Cardiac Arrest ◽  
Adverse Events ◽  
Spinal Anesthesia ◽  
Anaphylactoid Reaction ◽  
Descriptive Statistics ◽  
Anesthetic Techniques ◽  
Drug Error ◽  
Suspected Pulmonary Embolism ◽  
Contributing Factors ◽  
Incident Reports

Background: Spinal anesthesia is one of most common anesthetic techniques in Thailand. The Perioperative and Anesthetic Adverse Events in Thailand (PAAd Thai) Study was a multicentered project among 22 hospitals across the country to investigate the incidence of anesthesia related complications. Objective: To study the incidences of cardiac arrest and complication after spinal anesthesia including the contributing factors and suggested corrective strategies. Materials and Methods: This prospective descriptive study of the incident reports that occurred regarding spinal anesthesia collected from 22 participating hospital in the data collection between January and December of 2015 was completed. Three senior anesthesiologists reviewed the data and descriptive statistics were used. Results: Among 62,120 spinal anesthesia, there were 127 incidents (5.8%) among 2,206 incident reports related to anesthesia. There were seven cases of intraoperative cardiac arrest with an incidence of 1.13:10,000 spinal anesthesia (95% CI 0.55 to 2.33). Other complications were bradycardia with less than 40 beats per minute (50.4%), anaphylaxis or anaphylactoid reaction or drug allergy (14.2%), drug error (8.4%), coma or CVA or convulsion (3.9%), and suspected pulmonary embolism (3.9%). Adverse events occurred frequently with specialties or surgeries of orthopedics (44.1%), cesarean delivery (17.3%), urosurgery (17.3%), general surgery (14.2%), and gynecological surgery (4.7%), respectively. Conclusion: Contributing factors were inexperience, inappropriate decision making, haste, and inappropriate pre-anesthetic evaluation or preparation while factors minimizing incidents were vigilance, having experience, and experienced assistants. Suggested corrective strategies were quality assurance activity, guidelines especially monitoring, improvement of supervision, and additional training. Keywords: Spinal anesthesia, Adverse events, Incidents, Complications, Neuraxial anesthesia, Cardiac arrest

scholarly journals Neurosurgeons in 2020: the impact of gender on neurosurgical training, family planning, and workplace culture

2021 ◽  
Vol 50 (3) ◽  
pp. E11
Author(s):  
Jasmine A. Thum ◽  
Diana Chang ◽  
Nalini Tata ◽  
Linda M. Liau
Keyword(s):  
Gender Inequality ◽  
Online Survey ◽  
White Paper ◽  
Female Leadership ◽  
Contributing Factors ◽  
Midlevel Providers ◽  
Male Patients ◽  
Female Nurses ◽  
Age Range ◽  
The Impact

OBJECTIVEIn 2008, a Women in Neurosurgery Committee white paper called for increased women applicants and decreased women’s attrition in neurosurgery. However, contributing factors (work-life balance, lack of female leadership, workplace gender inequality) have not been well characterized; therefore, specific actions cannot be implemented to improve these professional hurdles. This study provides an update on the experiences of neurosurgeons in 2020 with these historical challenges.METHODSAn anonymous online survey was sent to all Accreditation Council for Graduate Medical Education (ACGME)–accredited US neurosurgical programs, examining demographics and experiences with mentorship, family life, fertility, and workplace conduct.RESULTSA total of 115 respondents (64 men, 51 women; age range 25–67 years) had trained at 49 different US residencies. Mentorship rates were very high among men and women in medical school and residency. However, women were significantly more likely than men to have a female mentor in residency. During residency, 33% of women versus 44% of men had children, and significantly fewer women interested in having a child were able to do so in residency, compared to men. Significantly more women than men had a child only during a nonclinical year (56.3% vs 19.0%, respectively). Thirty-nine percent of women and 25% of men reported difficulty conceiving. The major difficulty for men was stress, whereas women reported the physical challenges of pregnancy itself (workplace teratogens, morning sickness, etc.). Failed birth rates peaked during residency (0.33) versus those before (0.00) and after residency (0.25).Women (80%) experience microaggressions in the workplace significantly more than men (36%; p < 0.001). Ninety-five percent of macro-/microaggressions toward female neurosurgeons were about their gender, compared to 9% of those toward men (p < 0.001). The most common overall perpetrators were senior male residents and attendings, followed by male patients (against women) and female nurses or midlevel providers (against men).CONCLUSIONSAccurate depictions of neurosurgery experiences and open discussions of the potential impacts of gender may allow for 1) decreased attrition due to more accurate expectations and 2) improved characterization of gender differences in neurosurgery so the profession can work to address gender inequality.

scholarly journals AN ERROR ANALYSIS IN USING SIMPLE PAST TENSE IN INCIDENT REPORT E-MAILS BY KIDS CLUB SOFITEL STAFF

Widya Accarya ◽  
2020 ◽  
Vol 11 (1) ◽  
pp. 107-111
Author(s):  
I Gusti Ngurah Bagus Yoga Widiadnya
Keyword(s):  
Error Analysis ◽  
Qualitative Method ◽  
Past Tense ◽  
Incident Report ◽  
Problem Statement ◽  
Sources Of Error ◽  
Clear Explanation ◽  
The Common ◽  
Incident Reports ◽  
E Mail

Abstract This research aimed to find out the common errors of word order especially in using verb, to be, and noun phrase in writing incident report emails made by Kids club Sofitel staffs. The problem statement of this research was “what are the types and the sources of error on the use of simple past tense in Kids club incident reports by email writing”. The objective of this research was to find out the types and the sources of errors that often occurred in the use of simple past tense in incident reports made by Kids club Sofitel staffs. To analyze the data, the researcher used descriptive qualitative method and used error analysis procedure to make clear explanation. The error collected was classified based on Dulay Strategy Taxonomy. The participants of this study consist of five staffs from Kids club Sofitel Bali Nusa Dua. By this analysis, the researcher found errors as follows: there were 132 errors were found in the staff’s incident reports. The total errors of Omission were 64 errors, Addition were 5 errors and Mis-formation were 63 errors and also 109 errors of Intralingual transfer and 23 errors of Interlingual transfer. So could be concluded that the most of error found was Omission and lowest of error found was Addition and the most of sources of error was Intralingual transfer. Keywords: Error Analysis, Simple Past Tense, E-mail.   Abstrak Abstrak. Penelitian ini bertujuan untuk mengetahui kesalahan umum urutan kata terutama dalam menggunakan kata kerja, menjadi, dan frasa kata benda dalam menulis email laporan kejadian yang dibuat oleh staf Kids club Sofitel. Pernyataan masalah dari penelitian ini adalah "apa jenis dan sumber kesalahan tentang penggunaan simple past tense dalam laporan insiden Kids club dengan menulis email". Tujuan dari penelitian ini adalah untuk mengetahui jenis dan sumber kesalahan yang sering terjadi dalam penggunaan simple past tense dalam laporan insiden yang dibuat oleh staf Kids club Sofitel. Untuk menganalisis data, peneliti menggunakan metode deskriptif kualitatif dan menggunakan prosedur analisis kesalahan untuk membuat penjelasan yang jelas. Kesalahan yang dikumpulkan diklasifikasikan berdasarkan Dulay Strategy Taxonomy. Peserta penelitian ini terdiri dari lima staf dari Kids club Sofitel Bali Nusa Dua. Dengan analisis ini, peneliti menemukan kesalahan sebagai berikut: ada 132 kesalahan ditemukan dalam laporan insiden staf. Total kesalahan Kelalaian adalah 64 kesalahan, Penambahan 5 kesalahan dan Kesalahan informasi adalah 63 kesalahan dan juga 109 kesalahan transfer Intralingual dan 23 kesalahan transfer Interlingual. Jadi dapat disimpulkan bahwa sebagian besar kesalahan yang ditemukan adalah Kelalaian dan kesalahan terendah yang ditemukan adalah Penambahan dan sebagian besar sumber kesalahan adalah transfer Intralingual. Kata kunci: Analisis Kesalahan, Simple Past Tense, E-mail.

scholarly journals Linguistic validation of the simplified Chinese version of the US National Cancer Institute’s patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE™)

BMC Cancer ◽  
2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Cheng KKF ◽  
S. A. Mitchell ◽  
N. Chan ◽  
E. Ang ◽  
W. Tam ◽  
...  
Keyword(s):  
Adverse Events ◽  
Cancer Patients ◽  
Patient Reported Outcomes ◽  
A Priori ◽  
Cognitive Interviews ◽  
Simplified Chinese ◽  
Patient Reported ◽  
The Us ◽  
The Common ◽  
Response Choices

Abstract Background The aim of this study was to translate and linguistically validate the U.S. National Cancer Institute’s Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™) into Simplified Chinese for use in Singapore. Methods All 124 items of the English source PRO-CTCAE item library were translated into Simplified Chinese using internationally established translation procedures. Two rounds of cognitive interviews were conducted with 96 cancer patients undergoing adjuvant treatment to determine if the translations adequately captured the PRO-CTCAE source concepts, and to evaluate comprehension, clarity and ease of judgement. Interview probes addressed the 78 PRO-CTCAE symptom terms (e.g. fatigue), as well as the attributes (e.g. severity), response choices, and phrasing of ‘at its worst’. Items that met the a priori threshold of ≥20% of participants with comprehension difficulties were considered for rephrasing and retesting. Items where < 20% of the sample experienced comprehension difficulties were also considered for rephrasing if better phrasing options were available. Results A majority of PRO-CTCAE-Simplified Chinese items were well comprehended by participants in Round 1. One item posed difficulties in ≥20% and was revised. Two items presented difficulties in < 20% but were revised as there were preferred alternative phrasings. Twenty-four items presented difficulties in < 10% of respondents. Of these, eleven items were revised to an alternative preferred phrasing, four items were revised to include synonyms. Revised items were tested in Round 2 and demonstrated satisfactory comprehension. Conclusions PRO-CTCAE-Simplified Chinese has been successfully developed and linguistically validated in a sample of cancer patients residing in Singapore.

scholarly journals Coding ATC Incident Data Using HFACS: Intercoder Consensus

2011 ◽  
Vol 2011 ◽  
pp. 1-8 ◽  
Author(s):  
Liang Wang ◽  
Yaohua Wang ◽  
Xiaoqiang Yang ◽  
Kai Cheng ◽  
Haishan Yang ◽  
...  
Keyword(s):  
Human Factors ◽  
Traffic Control ◽  
Air Traffic ◽  
The Other ◽  
Contributing Factors ◽  
Factors Analysis ◽  
Air Traffic Controllers ◽  
High Hazard ◽  
Incident Reports ◽  
Comparability Of Results

Reliability studies for coding contributing factors of incident reports in high hazard industries are rarely conducted and reported. Although the Human Factors Analysis and Classification System (HFACS) appears to have a larger number of such studies completed than most other systems doubt exists as the accuracy and comparability of results between studies due to aspects of methodology and reporting. This paper reports on a trial conducted on HFACS to determine its reliability in the context of military air traffic control (ATC). Two groups participated in the trial: one group comprised of specialists in the field of human factors, and the other group comprised air traffic controllers. All participants were given standardized training via a self-paced workbook and then read 14 incident reports and coded the associated findings. The results show similarly low consensus for both groups of participants. Several reasons for the results are proposed associated with the HFACS model, the context within which incident reporting occurs in real organizations and the conduct of the studies.

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