How To Prevent Wrong-Site Nerve Blocks - NYSORA | NYSORA

How To Prevent Wrong-Site Nerve Blocks

June 29, 2022

The Joint Commission defines Wrong-Site Surgery (WSS) as an invasive procedure performed on the wrong part of the body, wrong side, or the wrong patient, thus exposing them to greater risk.

A WSNB immediately triggers root-cause analysis, quality assurance, and risk management committee meetings. It may require reporting to the state department of health and/or lead to disciplinary action, or even a license revocation in the case of repetitive error. More importantly, WSNB may lead to surgery on the wrong side, undesirable outcomes, and indefensible medico-legal consequences.

In spite of all this, wrong-site nerve blocks (WSNB) continue to be one of the most dreaded complications of nerve blocks.

A few years ago in my practice in New York, I was involved in a “block on the wrong side” incident. I remember that day like it was yesterday. I was called to the operating room to assist the trainee with an interscalene block.

Interscalene brachial plexus block; Reverse Ultrasound Anatomy with needle insertion in-plane. SCM, sternocleidomastoid; ASM, anterior scalene muscle; LCa, longus capitis muscle; VA, vertebral artery; MSM, middle scalene muscle; LTN, long thoracic nerve; DSN, dorsal scapular nerve; C7-TP, transverse process of C7.

As I entered the operating room, all checklists, patient preparation, prepping, and draping had already been done, and I assumed that it was all correct. As we finished with the nerve block procedure and took the drapes off, I noticed to my dismay! – that the arm on the side on which we performed the block had a blood pressure cuff and an IV.

After removing the drape it was revealed that the nerve block was performed on the side where the patient had an IV and blood pressure cuff.

In a split second, I came out in a cold sweat because it meant that – despite all the checklists – they had prepped the wrong side and we had performed the block on the wrong side. Needless to say, in addition to the unnecessary nerve block procedure, this created an inconvenience and risk for the patient, cancellation of the surgery, and an administrative nightmare for everyone involved.

Anesthesiologist and nurses after they realized the block was performed on the wrong side.

I thought about this for days and I kept rewinding the film, trying to work out what we could do to prevent this from happening. What could we do to grab attention, to flag up a strong signal as a reminder to perform the one final, last time-out and checklist BEFORE the needle goes in?

Now, while we know the value of checklists to reduce errors in the medical world, their effectiveness depends on the conscious attention of the practitioners. With so many checklists to be completed on the patient’s journey to the operating theater, the risk is that they become routine. The ‘checklist fatigue’ can lead to situations where providers forget to execute the checklist at the place where it matters most: point of care, immediately prior to the nerve block administration.

The WHO surgical safety checklist (2009).

Measures to reinforce checklists at the point of care vary considerably from institution to institution. One example is the restricted needle technique, used at HSS where, per protocol, the nurses only provide the needle to the practitioner after the site verification has been confirmed and agreed. The problem with this is that the nurses report frustration with yet another responsibility, and the anesthesia providers may resent the loss of their autonomy if the block needles are removed from the anesthesia cart.

Removing the block needles from the anesthesia cart.

But no generally-accepted standards exist, and, despite the checklists, WSNB still occurs. So, how do we make sure that the critical “one last checklist” is given the full attention it deserves?

The answer may lie in some sort of a physical barrier that prevents the use of the ultrasound machine until the point of care checklist is done. And here’s the answer we came up with: NYSORA collaborated with the industry to develop the first probe covers specifically developed for ultrasound-guided nerve blocks.

EZCOVER® STOP probe cover.

In our practice of nerve blocks at NYSORA, we have adopted ultrasound probe covers that feature an easy-to-remove sticker that bears the message “STOP before you BLOCK”.  The sticker presents an actual physical barrier that must be removed before the ultrasound can be used to acquire images.

This is a strong visual reminder to do that crucial  “ONE LAST checklist” – a time-out to be sure that we have the correct patient, procedure, and laterality before the needle goes into the patient.

Let us know whether a block on the wrong side in your practice ever occurred? And what YOU do in your practice to prevent the wrong-site blocks. Feel free to post your comments on this link:

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