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Wrong-site regional anesthesia: review and recommendations for prevention?
Michael J Barrington1, Yoshiaki Uda, Simon J Pattullo
1aDepartment of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital, Melbourne bFaculty of Medicine, Melbourne Medical School, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria cDepartment of Anaesthesia, Gold Coast University Hospital, Southport, Queensland, Australia dDepartment of Anesthesiology and Pain Management, Dartmouth-Hitchcock Medical Center, Lebanon eGeisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
Wrong-site regional anesthesia blocks are preventable never events. Implementing checklists and mandatory preoperative site verification with time-outs can significantly reduce their occurrence.
Area of Science:
- Anesthesiology
- Patient Safety
- Surgical Procedures
Background:
- Wrong-site regional anesthetic procedures are classified as never events, highlighting critical patient safety concerns.
- Understanding the contributing factors is essential for developing effective prevention strategies.
Purpose of the Study:
- To describe the phenomenon of wrong-site regional anesthetic blocks.
- To identify and review strategies for preventing these errors.
Main Methods:
- Review of literature on wrong-site regional anesthetic blocks.
- Analysis of contributing factors and existing preventive guidelines.
Main Results:
- The incidence of wrong-site blocks is estimated at 7.5 per 10,000 procedures.
- Contributing factors include communication failures, documentation issues, patient positioning changes, and lapses in situational awareness.
- The American Society of Regional Anesthesia and Pain Medicine has developed a 9-point checklist.
Conclusions:
- Mandatory preoperative site verification and surgical site marking are crucial.
- A time-out procedure immediately before invasive procedures is essential for confirming patient and block site.
- Consistent implementation of guidelines and checklists by anesthetic teams is vital for reducing wrong-site blocks.
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