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


Correspondence to: Dr M. T. Kluger E-mail:


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.