Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS)

Summary Four hundred and nineteen incidents that occurred in the recovery room were extracted from the Anaesthetic Incident Monitoring Study database, representing 5% of the total database of 8372 reports. Incidents were reported mainly in daylight hours, with over 50% occurring in ASA 1–2 patients....

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Bibliographic Details
Published in:Anaesthesia 2002-11, Vol.57 (11), p.1060-1066
Main Authors: Kluger, M. T., Bullock, M. F. M.
Format: Article
Language:English
Subjects:
Adolescent
Adult
Anaesthesia recovery period
Anesthesia
Anesthesia Recovery Period
Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy
Australia - epidemiology
Biological and medical sciences
Child
Child, Preschool
Complications: postoperative
Databases, Factual
Heart Arrest - etiology
Humans
Infant
Medical Errors
Medical sciences
Medication Errors
Miscellaneous
Outcome and process assessment
Outcome and Process Assessment (Health Care)
Postoperative Care - adverse effects
Postoperative Complications - epidemiology
Postoperative Complications - prevention & control
Recovery room
Recovery Room - standards
Recovery Room - statistics & numerical data
Risk Factors
Risk Management
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Summary:Summary Four hundred and nineteen incidents that occurred in the recovery room were extracted from the Anaesthetic Incident Monitoring Study database, representing 5% of the total database of 8372 reports. Incidents were reported mainly in daylight hours, with over 50% occurring in ASA 1–2 patients. The most common presenting problems related to respiratory/airway issues (183; 43%), cardiovascular problems (99; 24%) and drug errors (44; 11%). One hundred and twenty‐two events (29%) led to a major physiological disturbance and required management in the High Dependency Unit or Intensive Care Unit. Contributing factors cited included error of judgement (77; 18%), communication failure (57; 14%) and inadequate pre‐operative preparation (29; 7%), whilst factors minimising the incident included previous experience (97; 23%), detection by monitoring (72; 17%) and skilled assistance (54; 13%). Staffing and infrastructure of the recovery room needs to be supported, with ongoing education and quality assurance programmes developed to ensure that such events can be reduced in the future.
ISSN:0003-2409
1365-2044
DOI:10.1046/j.1365-2044.2002.02865.x