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

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

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

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 European registry of type A aortic dissection (ERTAAD) - rationale, design and definition criteria

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Fausto Biancari ◽  
Giovanni Mariscalco ◽  
Hakeem Yusuff ◽  
Geoffrey Tsang ◽  
Suvitesh Luthra ◽  
...  
Keyword(s):  
Adverse Events ◽  
Aortic Dissection ◽  
Treatment Strategies ◽  
Kidney Injury ◽  
Type A ◽  
Salvage Procedure ◽  
Type A Aortic Dissection ◽  
Mortality And Morbidity ◽  
Link Type ◽  
The Impact

Abstract Background Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition. Surgery is usually performed as a salvage procedure and is associated with significant postoperative early mortality and morbidity. Understanding the patient’s conditions and treatment strategies which are associated with these adverse events is essential for an appropriate management of acute TAAD. Methods Nineteen centers of cardiac surgery from seven European countries have collaborated to create a multicentre observational registry (ERTAAD), which will enroll consecutive patients who underwent surgery for acute TAAD from January 2005 to March 2021. Analysis of the impact of patient’s comorbidities, conditions at referral, surgical strategies and perioperative treatment on the early and late adverse events will be performed. The investigators have developed a classification of the urgency of the procedure based on the severity of preoperative hemodynamic conditions and malperfusion secondary to acute TAAD. The primary clinical outcomes will be in-hospital mortality, late mortality and reoperations on the aorta. Secondary outcomes will be stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. Discussion The analysis of this multicentre registry will allow conclusive results on the prognostic importance of critical preoperative conditions and the value of different treatment strategies to reduce the risk of early adverse events after surgery for acute TAAD. This registry is expected to provide insights into the long-term durability of different strategies of surgical repair for TAAD. Trial registration ClinicalTrials.gov Identifier: NCT04831073.

scholarly journals Attitudes and compliance with the WHO surgical safety checklist: a survey among surgeons and operating room staff in 138 hospitals in China

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Jie Tan ◽  
James Reeves Mbori Ngwayi ◽  
Zhaohan Ding ◽  
Yufa Zhou ◽  
Ming Li ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Operating Room ◽  
World Health ◽  
Surgical Patient ◽  
Local Data ◽  
Cross Sectional ◽  
Surgical Safety Checklist ◽  
Surgical Safety ◽  
Operating Room Staff

Abstract Background Ten years after the introduction of the Chinese Ministry of Health (MoH) version of Surgical Safety Checklist (SSC) we wished to assess the ongoing influence of the World Health Organisation (WHO) SSC by observing all three checklist components during elective surgical procedures in China, as well as survey operating room staff and surgeons more widely about the WHO SSC. Methods A questionnaire was designed to gain authentic views on the WHO SSC. We also conducted a prospective cross-sectional study at five level 3 hospitals. Local data collectors were trained to document specific item performance. Adverse events which delayed the operation were recorded as well as the individuals leading or participating in the three SSC components. Results A total of 846 operating room staff and surgeons from 138 hospitals representing every mainland province responded to the survey. There was widespread acceptance of the checklist and its value in improving patient safety. 860 operations were observed for SSC compliance. Overall compliance was 79.8%. Compliance in surgeon-dependent items of the ‘time-out’ component reduced when it was nurse-led (p < 0.0001). WHO SSC interventions which are omitted from the MoH SSC continued to be discussed over half the time. Overall adverse events rate was 2.7%. One site had near 100% compliance in association with a circulating inspection team which had power of sanction. Conclusion The WHO SSC remains a powerful tool for surgical patient safety in China. Cultural changes in nursing assertiveness and surgeon-led teamwork and checklist ownership are the key elements for improving compliance. Standardised audits are required to monitor and ensure checklist compliance.

scholarly journals A Paradigm Shift in Critical Care Infrastructure in Complex Settings: Evaluating an Ultraportable Operating Room to Improve Field Surgical Safety

2021 ◽  
Vol 186 (Supplement_1) ◽  
pp. 295-299
Author(s):  
Debbie L Teodorescu ◽  
Stephen Okajima ◽  
Asad Moten ◽  
Mike H M Teodorescu ◽  
Majed El Hechi ◽  
...  
Keyword(s):  
Operating Room ◽  
In Silico ◽  
Environmental Control ◽  
External Environment ◽  
Control Unit ◽  
Mortality And Morbidity ◽  
Particle Count ◽  
Surgical Safety ◽  
Surgical Field ◽  
Complex Settings

ABSTRACT Introduction Scarcity of operating rooms and personal protective equipment in far-forward field settings make surgical infections a potential concern for combat mortality and morbidity. Surgical and transport personnel also face infectious risks from bodily fluid exposures. Our study aimed to describe the serial, proof-of-concept testing of the SurgiBox technology: an inflatable sterile environment that addresses the aforementioned problems, fits on gurneys and backpacks, and drapes over incisions. Materials and Methods The SurgiBox environmental control unit and inflatable enclosure were optimized over five generations based on iterative feedback from stakeholders experienced in surgery in austere settings. The airflow system was developed by analytic modeling, verified through in silico modeling in SOLIDWORKS, and confirmed with prototype smoke-trail checking. Particulate counts evaluated the enclosure’s ability to control and mitigate users’ exposures to potentially infectious contaminants from the surgical field in various settings. SurgiBox enclosures were setup over a mannequin’s torso, in a configuration and position for either thoracic or abdominal surgery. A particle counter was serially positioned in sternotomy and laparotomy positions, as well as bilateral flank positions. This setup was repeated with open ports exposing the enclosure to the external environment. To simulate stress scenarios, sampling was repeated with enclosure measurements during an increase in external particulate concentration. Results The airflow technology effectively kept contaminants away from the incision and maintained a pressure differential to reduce particle entry. Benchtop testing demonstrated that even when ports were opened or the external environment had high contaminant burden, the enclosed surgical field consistently registered 0 particle count in all positions. Time from kit opening to incision averaged 54.5 seconds, with the rate-limiting step being connecting the environmental control unit to the enclosure. The portable kit weighted 5.9 lbs. Conclusions Analytic, in silico, and mechanical airflow modeling and benchtop testing have helped to quantify the SurgiBox system’s reliability in creating and maintaining an operating room-quality surgical field within the enclosure as well as protecting the surgical team outside the enclosure. More recent and ongoing work has focused on specifying optimal use settings in the casualty chain of care, expanding support for circumferential procedures, automating airflow control, and accelerating system setup. SurgiBox’s ultimate goal is to take timely, safe surgery to patients in even the most austere of settings.

scholarly journals STMO-07 Adverse events related to the glioblastoma surgery and their perioperative management in our hospital

2020 ◽  
Vol 2 (Supplement_3) ◽  
pp. ii10-ii10
Author(s):  
Hideki Kashiwagi ◽  
Shinji Kawabata ◽  
Seigo Kimura ◽  
Ryokichi Yagi ◽  
Naokado Ikeda ◽  
...  
Keyword(s):  
Adverse Events ◽  
Venous Thrombosis ◽  
Perioperative Management ◽  
Perioperative Complications ◽  
Epileptic Seizures ◽  
Residual Tumor ◽  
Complete Removal ◽  
Tumor Localization ◽  
Vein Thrombosis ◽  
Before And After

Abstract Background: The standard treatment for glioblastoma is surgical resection following chemoradiation therapy. The rate of removal or the amount of residual tumor has some impact on the prognosis of patients with glioblastoma, but the highly invasive nature of this tumor makes complete removal limited to the contrast-enhanced lesions difficult due to its localization. Furthermore, when postoperative seizures and venous thrombosis are included in surgery-related complications, these perioperative adverse events can cause delays in the initiation of chemoradiotherapy and delay the return to work and home, such as prolonged hospitalization and rehabilitation time. Methods: We retrospectively reviewed the perioperative status of the recent 50 consecutive cases with histologically confirmed as glioblastoma at our hospital, the patient background, tumor localization, and perioperative treatment, and so on. Results: The major perioperative complications were ischemic or hemorrhagic complications, epileptic seizures, venous thrombosis, and pneumonia; CTCAE grade 2 or higher, grade 3 or higher, and grade 4 occurred in about 40%, 20%, and 10%, respectively, with some patients having multiple complications. Discussion: Although there was a tendency for ischemic changes around the cavity of the resection as the resection rate increased, most cases were asymptomatic and it seemed to be acceptable if residual brain function could be preserved. Residual tumors tended to show hemorrhagic changes and epileptic seizures because this is thought to be that the tumor was deliberately left in place to preserve function, based on the localization of the tumor. Postoperative FDP levels were useful in predicting the development of deep vein thrombosis and pulmonary artery thromboembolism. Conclusion: Because glioblastoma has short survival time and patient PS before and after surgery varies greatly depending on tumor localization, it is important to consider risk-benefit strategies for each case and to establish a scheme for a seamless transition from perioperative management to the introduction of postoperative therapy and maintenance therapy.

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.

scholarly journals Adverse events in radiation oncology: A case series from wake up safe, the pediatric anesthesia quality improvement initiative

2019 ◽  
Vol 29 (3) ◽  
pp. 265-270 ◽  
Author(s):  
Robert E. Christensen ◽  
Rebecca C. Nause-Osthoff ◽  
Jeffrey C. Waldman ◽  
Daniel E. Spratt ◽  
Jason W. D. Hearn
Keyword(s):  
Quality Improvement ◽  
Adverse Events ◽  
Radiation Oncology ◽  
Pediatric Anesthesia ◽  
Case Series ◽  
Quality Improvement Initiative
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