Klanarong Sireeluck, Chau-in Waraporn, Pulnitiporn Aksorn, Pengpol Wiroj
Department of Anesthesia, Bhudhachinaraj Hospital, Phitsanulok, Thailand.
J Med Assoc Thai. 2005 Nov;88 Suppl 7:S134-40.
Anesthesia equipment problems may contribute to anesthetic morbidity and mortality. In Thailand, the magnitude and pattern of these problems has not been established. We therefore analyzed the frequency, type and severity of equipment-related problems, and what additional efforts might be needed to improve safety.
The data were drawn from the Thai Anesthesia Incidents Study (THAI Study) between February 1, 2003 and July 31, 2004 in which anesthesia-related data (i.e. of perioperative problems and their severity) were recorded (by the attending anesthesiologist) from all anesthetic cases on a routine basis. We selected cases under general and regional anesthesia with anesthetic equipment failure/malfunction for descriptive analysis.
The frequency of anesthetic equipment problems of the 202,699 recorded cases was approximated 0.04% or 1 : 2252. Two-thirds of the problems (63%) involved the anesthesia machine and of these incidents 73 and 41 percent involved system and human errors, respectively. One patient died and one suffered permanent morbidity.
The incidence and severity of equipment problems was low. Aside from improvements to pre-operative equipment checks, vigilance, continuous quality improvement and quality assurance activities were suggested as strategies to reduce problems.
麻醉设备问题可能导致麻醉相关的发病率和死亡率。在泰国，这些问题的严重程度和模式尚未明确。因此，我们分析了与设备相关问题的发生频率、类型和严重程度，以及为提高安全性可能需要的额外措施。
数据来自2003年2月1日至2004年7月31日的泰国麻醉事件研究（THAI研究），在此期间，主治麻醉医生会定期记录所有麻醉病例的麻醉相关数据（即围手术期问题及其严重程度）。我们选取全身麻醉和区域麻醉中出现麻醉设备故障/失灵的病例进行描述性分析。
在记录的202,699例病例中，麻醉设备问题的发生频率约为0.04%，即1:2252。三分之二的问题（63%）涉及麻醉机，其中73%和41%的事件分别涉及系统和人为错误。有1例患者死亡，1例出现永久性并发症。
设备问题的发生率和严重程度较低。除了改进术前设备检查外，还建议提高警惕、持续改进质量和开展质量保证活动，以此作为减少问题的策略。
