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Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS)
Author(s) -
Kluger M. T.,
Bullock M. F. M.
Publication year - 2002
Publication title -
anaesthesia
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.839
H-Index - 117
eISSN - 1365-2044
pISSN - 0003-2409
DOI - 10.1046/j.1365-2044.2002.02865.x
Subject(s) - medicine , incident report , staffing , quality assurance , medical emergency , intensive care unit , unit (ring theory) , daylight , near miss , judgement , emergency medicine , intensive care medicine , nursing , computer security , forensic engineering , physics , external quality assessment , mathematics education , mathematics , pathology , computer science , optics , law , political science , engineering
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.