Archive November 2018 XIX, No. 11

Anesthesia Alert: Tips to Avoid Wrong-Site Nerve Blocks

Regional anesthesia has its own set of safety principles.

Donald Martin

Donald Martin, MD


PRE-NERVE BLOCK TIME OUT During the block time-out, both the anesthesia provider and the RN block team member should verify the procedure and its laterality that are documented on the surgical consent.

Same-day surgery is vulnerable to the risk factors of wrong-site blocks, notably time pressure to stay on schedule, distraction, inadequate communication and hard-to-see site marks. Plus, in many facilities, anesthesia providers care for the same patients in the OR on whom they placed nerve blocks. Here are some tips from the Pennsylvania Patient Safety Authority and Pennsylvania Society of Anesthesiologists' "Principles for Reliable Performance of Correct-Site Nerve Blocks" ( Like most safety measures, it starts in pre-op.

1Pre-operative verification Confirm patient identity using at least 2 forms of patient identification. Reconcile and verify the exact site and laterality of the surgical procedure and the nerve block site using all forms of available primary and confirmatory patient sources, including the surgical consent, the patient (or relative), the OR schedule, and the history & physical. If any sources differ, stop the process and alert the surgeon to resolve the disagreement.

2Anesthesia site marking After confirming the patient's identity, the attending anesthesiologist (not a trainee) will use a standardized mark that is distinct from the one used for the surgical site to mark the perioperative nerve block site. Place the mark close to the injection site to ensure it is visible in the prepped and draped field. Repeat the marking process when there are multiple injection sites.

3Time out Secure a block team consisting of at least 2 people with independent roles (attending anesthesiologist and pre-op or holding area nurse or circulating nurse). The anesthesiologist should initiate or ask for the time out. Conduct a time out before sedating the patient (when possible), before inserting the needle (or as close to the procedure as possible) and before each nerve block.

Already on it

One facility that already is taking steps to help to ensure blocks are being performed at the correct site is Memorial Healthcare System in Hollywood, Fla. They have patients wear a green wristband on the side of the block. They also have their patients read from a script during the time out, using questions that confirm important information related to the site and the procedure.

Wrong-site blocks occur more often that you might imagine. They occurred 10 times more often than wrong-site surgery at the University of Pittsburgh Medical Center from 2009 to 2012, according to a study published in the British Journal of Anaesthesia. More than one-fourth (26%) of all wrong-site procedures reported to the Pennsylvania Patient Safety Authority from 2004 to 2017 were wrong-site blocks. Follow these tips and together we can watch those numbers dwindle. OSM

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