Wrong-site nerve blocks: evidence-review and prevention strategies

Abstract

Purpose of review There has been increasing attention to wrong site medical procedures over the last 20 years. This review aims to provide a summary of the current understanding and recommendations for the prevention of wrong-site nerve blocks (WSNB). Recent findings Various procedural, patient, practitioner, and organizational factors have been associated with the risk of WSNB. Recent findings have suggested that the use of a checklist is likely to reduce the incidence of WSNB. However, despite the widespread use of preprocedural checklists, WSNB continue to occur at significant frequency. This may be due to the inability of practitioners and teams to implement checklists correctly or the cognitive errors that prevent checklists from being executed as designed. Summary Though the evidence is limited, it is recommended that a combination of multiple strategies should be employed to prevent WSNB. These include the use of preprocedural markings, well constructed checklists, time-out/stop-moments, and cognitive/physical aids. Effective implementation requires team education and engagement that empowers all team members to speak up as part of a culture of safety.

Why don’t clinicians use checklists?

“…9 Wrong-sided blocks (WSBs) constitute the most common wrong-side procedure in the perioperative setting, with an incidence in the range of 0.52 to 5.07 WSBs per 10,000 blocks. 10,11 Various factors contribute to errors in regional blocks, such as time pressure, case volume, production demand, inadequate supervision, personnel changes, cognitive error, reliance on memory, incompetence, fatigue, lack of understanding of safety protocol, delays, interruptions, teaching, and intervening procedure. Factors associated with the WSB are procedures performed outside of the operating room, surgical marks not present, more than one block performed, changes in the operating schedule, and inaccurate information from the patient.…”

“…Hence, the term “never event” was created, with the task of eliminating its incidence 9 . Wrong-sided blocks (WSBs) constitute the most common wrong-side procedure in the perioperative setting, with an incidence in the range of 0.52 to 5.07 WSBs per 10,000 blocks 10,11 …”

Regional Anesthesia in Upper-Limb Surgery

“…Safety protocols, checklists, and procedural timeouts have been increasingly used over the last decade. Their use is now considered criterion standard in reducing rare but serious adverse outcomes 63 …”

SP11 Wrong sided blocks& organization of the block room

“…1 Experts perform complex tasks more completely and make fewer errors than non-experts. 2 Errors in procedural healthcare cause harm. 1,3 Errors and associate harm are entirely avoidable by improving technical performance.…”