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If you think wrong site blocks are 'never events'... think again
ESRA Academy. Van Zundert A. Mar 6, 2017; 170344
André Van Zundert
André Van Zundert
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Almost 1 in 1000 patients are exposed to ‘wrong-site/wrong side of the body/wrong patient’ regional anaesthesia block procedures, with a significant proportion (56%) being near misses. Is it negligence? Should that not be reduced to virtually zero? The outcome is shocking to the anaesthesia community, and devastates patients and specialists. Most probably the incidence is much higher due to doctors’ unwillingness to publish their mistakes and few journals are interested in publishing case reports without new learning points.
Barrington et al list some 15 factors contributing to why these mishaps still occur, despite the existence of a RAPM 9-point checklist and they summarize 13 wrong-site block events identified from the literature. The authors reported wrong-site regional anaesthesia blocks analysed using the HEAPS (Human Error And Patient Safety) analysis tool, which identifies key factors such as patient, task (regional blockade), anaesthetist facilitator, team members, workplace and organisational factors and formulates a concise review of the incident.
Wrong-site errors/procedures of symmetrical human structures are preventable medical errors, both in surgical and pain procedures. It can occur during the administration of the patient (operation list, consent form, surgical/anaesthesia notes), the preparation period and the intervention itself. Suggested preventable steps include: a) an adequately performed block sign-in and time-out procedure (conducted immediately prior to the block placement, that needs to be repeated every time the patient changes position, or when the anaesthetist leaves the room for a short while) in a quiet environment, in the presence of the whole team; b) verbal verification of the clearly visible (adequate ambient light, area not covered by drapes) marked surgical site/side (which remains visible after skin preparation) – in the presence of the awake patient (able to adequately communicate with the surgical team – be aware of language/cultural/cognitive problems and sedated/comatose patients) – with the medical and anaesthesia record and the surgical consent form, immediately before the intervention, without changing the patient’s position; c) at least two team members should verify the correct side and check the site of the intervention; d) avoiding distraction (phone calls, time pressure, haste, busy list, running late, discussions with other team members, poor team communication, inexperience), fatigue and cognitive overload, prolonged delay after WHO sign-in step Safe Surgical Checklist and the actual block placement; e) be aware that a remote environment is more error prone; f) consistent adherence to well-designed robust protocols, guidelines and checklist; and g) organising routine system accountability for errors, periodic education sessions and teambased simulation on how to correctly perform sign-in, time-out and sign-out procedures. To ‘err is human’ – but we need to take every step possible to prevent left-right confusion and medical mishaps from occurring, as our patients should not be exposed to events that never need to occur. Be proactive in catching errors before they reach the patient: ‘Stop Before You Block’!

PURPOSE OF REVIEW:

Wrong-site regional anesthetic procedures are considered never events. The purpose of this review is to describe the phenomenon of wrong-site regional anesthetic blocks and identify preventive strategies.

RECENT FINDINGS:

The incidence of wrong-site block may be as frequent as 7.5 per 10,000 procedures. Factors contributing to wrong-site block include physician distraction, patient position change, scheduling changes, inadequate documentation, poor communication, lack of surgical consent, site marking not visible, inadequate supervision, reduced situational awareness, fatigue, cognitive overload, perceived time pressure, delay from World Health sign-in to block performance and omission of block time-out or block time-out occurring before final patient positioning. The American Society of Regional Anesthesia and Pain Medicine have created a 9-point checklist for regional anesthesia procedures.

SUMMARY:

Preoperative site verification and surgical site marking are mandatory. A time-out should occur immediately before any invasive procedure. Confirming the correct patient and block site with a time-out should occur immediately before all regional anesthetic procedures. If more than one block is performed on one patient, it is recommended that time-out be repeated each time the patient position is changed or separated in time or performed by a different team. The anesthetic team should uniformly implement robust guidelines and checklists to reduce the occurrence of wrong-site regional anesthetic procedures.

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