Anesthesia Department Management: Wrong Site Blocks
Author : Doc Clemens
More than 40 times each week in the United States, a surgeon cuts into a patient or an anesthesiologist places a nerve block, only to realize that the scalpel or needle belonged somewhere else
The true incidence of wrong-site surgery may be substantially higher because these errors are generally self-reported and are not always anonymous, which may discourage reporting (Arch Surg 2010; 145:984). And the problem persists despite widespread adoption of the Joint Commission’s Universal Protocol starting in July 2004 and other patient safety measures. Anesthesia providers are responsible for a growing share of these “sentinel events,” especially involving wrong-site local and regional anesthesia blocks. In Pennsylvania, for instance, the share of errors attributed to wrong-site blocks jumped from 20% of the total in 2004 to 44% in 2009 which is because surgeons have made improvements, but anesthesia staff have not. Surgeons have been applying the Universal Protocol the way it was intended, including verification, marking the site and performing the time-out but anesthesia providers, if anything, did verifications but hardly ever did markings. Anesthesia staff generally are not doing the time-out with an independent party and if they do it is only did a rudimentary form of verification.
Anesthesiologists or CRNAs placing regional blocks in the holding area should perform their own “block time-out,” involving an additional person who confirms the patient, procedure and laterality. The second person could be the surgeon, a circulating nurse from the OR or a nurse from the holding area.