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OVER COMING A 'NEVER EVENT', A COMPLETED AUDIT CYCLE OF 'STOP BEFORE YOU BLOCK'
Author(s): ,
Hartford-Beynon, J.*
Affiliations:
North Bristol NHS Foundation Trust, Department of Anaesthesia, Bristol, United Kingdom
Harrington, S.
Affiliations:
North Bristol NHS Foundation Trust, Department of Anaesthesia, Bristol, United Kingdom
ESRA Academy. Hartford-Beynon J. Sep 13, 2017; 190883; 170 Topic: Safety of Regional Anaesthesia - Complications - General Aspects
Dr. Jake Hartford-Beynon
Dr. Jake Hartford-Beynon

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Abstract
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Background and Aims:

“Stop before you block” (SB4YB) originated in the United Kingdom after episodes of wrong sided blocks.

The SB4YB campaign has been widely adopted throughout regional anesthesia and is part of patient safety culture.

In 2015/16 wrong sided block was classified as a “never event” by NHS improvement. We were unfortunate enough to have two wrong sided blocks in a 12 months.

We aimed to identify the reasons for this and reduce further occurrences.

Methods:

An audit of regional anesthetics and compliance with SB4YB was undertaken, after which an educational campaign was initiated. In addition a new question about unilateral regional anesthetic was added to the WHO sign in.

A repeat audit was performed to assess the success of this, thus completing the audit cycle.Results:

The first audit showed 70% compliance rate with SB4YB.

SB4YB was initiated by the primary anesthetist 41%, secondary anesthetist 38%, anesthetic assistant in conjunction with the anesthetist 12% and by the anesthetic assistant alone in 9% of cases respectively.  

Repeat audit showed a 97.8% compliance rate. Initiation of SB4YB was by the primary anesthetist 33.3%, secondary anesthetist 17.7%, anesthetic assistant in conjunction with the anesthetist 11.1% and the anesthetic assistant alone in 35.5% of cases respectively.Conclusions:

It is possible with education/awareness campaigns aimed at the theater team as well as the medical team to improve SB4YB compliance and thus improve patient safety.

We believe that the increase in compliance was primarily due to the increased initiation of SB4YB by the anesthetic assistant and use of a new WHO sign in.  

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