September 24, 2018

Publication of the seminal report To Err is Human in 1999 thrust wrong-patient, wrong-procedure, wrong-side, wrong-site surgery into the spotlight, catalyzing the Joint Commission’s introduction of the Universal Protocol and surgical timeouts in 2004, including timeouts led by attending anesthesiologists before placing nerve blocks.

Along with wrong-site surgery, the wrong-site nerve block (WSB) also holds status as a “never event,”—a serious, preventable patient safety incident that should never occur. But it hasn’t drawn the same level of attention, possibly because the consequences of a WSB are generally less serious than wrong-site surgery. That might be why less is known about why they happen and how they can be prevented.

At the same time, the timeout’s effectiveness as a preventive strategy has received mixed reviews. Despite widespread implementation of the Universal Protocol, wrong-site surgery and WSBs continue to occur.

“Just having a policy in place, no matter how robust it may be, doesn’t completely eliminate wrong-site blocks, because it relies on people following the policy,” anesthesiologist Mark Hudson, MD, MBA, of the University of Pittsburgh Medical Center (UPMC) observed in Anesthesiology News.

Prevention of WSBs warrants the anesthesia team’s steadfast attention. Though rare, the experience is distressing and harmful to patients when it happens. Complications, though usually less serious than wrong-site surgery, can be severe. A WSB can expose the anesthesiologist and the hospital to a lawsuit. And as anesthesiologists continue to move from opioids to multimodal anesthetics to reduce postsurgical complications, nerve block frequency, already on the rise within many anesthesia practices, will continue to grow, underscoring the need for heightened WSB prevention.

Research also indicates that WSBs are much more common than wrong-site surgery—about 10 times so, according to a 2015 study by UPMC anesthesiologists.  Offering the first incidence data on WSBs in a large patient population, the study found a WSB prevalence of 1.28 per 10,000 unilateral procedures between 2003 and 2012 and a ten-fold incidence of WSBs compared to wrong-site surgeries (1.01 per 10,000 patients versus 0.10 per 10,000 patients) during a four-year period (2009-2012) at their institution.

The study saw a trend toward a reduced incidence of WSBs following UPMC’s implementation of a system-wide timeout policy, but the small number of WSBs limited a definitive analysis. “The environment in which nerve blocks are performed—where each team member may have other obligations and there is inconsistency in who is available during the process—presents unique challenges for policies aimed at preventing wrong-site blocks,” noted the authors, including UPMC’s Dr. Hudson.

These findings, and data from the Pennsylvania Patient Safety Reporting System showing that WSBs comprise nearly 26 percent of all wrong-site procedures reported in Pennsylvania since 2004, were among the drivers of collaboration between the Pennsylvania Patient Safety Authority and the Pennsylvania Society of Anesthesiologists that has led to a new peer-driven protocol.  Developed by a multidisciplinary team of anesthesiologists, patient representatives, nurses, surgeons and consultants, the multi-pronged protocol attacks WSBs from clinical, cultural and environmental angles.

The organizations partnered to address the slower rate of adoption of wrong-site prevention practices among anesthesiologists and perioperative teams than among surgical teams, starting with a systematic review of the literature, from which five themes emerged regarding the causes of WSBs:  1) time pressure, including production demand; 2) personnel issues, including complacency and fatigue; 3) block site marks that were not visible or missing; 4) distractions and interruptions; and 5) inadequate communication, including language barriers, documentation deficiencies and use of abbreviations.

Using the literature review, interviews, and a survey in which members rated their level of agreement with a list of 66 practices, the task force reached consensus on a final set of 21 Principles for Reliable Performance of Correct-Site Nerve Blocks, including 12 process of care practices and nine healthcare facility structure and culture of care practices.

According to an article on the protocol by Theresa V. Arnold, DPM, of the Pennsylvania Patient Safety Authority, and Donald E. Martin, MD, of the Pennsylvania Society of Anesthesiologists, the peer-driven, consensus-based protocol’s grounding in multidisciplinary perspectives; use of primary and confirmatory preoperative sources, including patients, to verify the exact location and laterality of the surgical site; use of specific site-marking and timeout procedures based on identified needs; and consideration for the culture and environment in which nerve blocks are performed can help organizations achieve lasting results. They encourage anesthesiologists to work with their organizations to establish the principles as standard surgical safety practices (see figure below).

Source:  ASRA News, American Society of Regional Anesthesia and Pain Medicine, August 2018.  https://www.asra.com/asra-news/article/102/peer-driven-principles-promote-correct-s

Memorial Healthcare System, the fifth largest public healthcare system in the country, has also developed an innovative approach to WSB prevention based on two ideas generated by a Lean-based rapid improvement process:  1) visual confirmation of laterality, in which the patient wears a colored wrist band on the operative side for easy visibility and rapid identification; and 2) “patient-led” timeouts, in which the patient reads the script. More information about the new protocol is available here.

Has your group found an innovative way to prevent WSBs?  Share your experiences with us.

With best wishes,

Tony Mira
President and CEO