When left isn't right: A case series of wrong-sided nerve blocks reported to webAIRS

The aim of this study was to review cases of wrong-sided nerve blockade among the 11,425 incidents reported to webAIRS-a centralised Australian and New Zealand anaesthetic incident reporting system-as of April 2024. Cases were reviewed if a reporter selected 'peripheral nerve blockade' as a main category, or narrative word search identified the terms 'wrong/incorrect/error' and 'site/side'. Seven hundred and seventy-one reports under the category 'peripheral nerve blockade' were reviewed, and 43 incidents were ultimately included for analysis, involving 38 wrong-sided blocks and five near misses. Both quantitative and qualitative factors contributing to laterality errors were assessed by two independent analysers. Although most incidents of wrong-sided block had minimal reported sequelae, one patient required unplanned admission to intensive care, while another had an operation cancelled. Wrong-side blockade remains a 'never event', and its occurrence can have significant physical and psychological consequences for patients. Regional anaesthetic errors are contributed to by various factors that have been well described in previous publications on the topic; however, this study demonstrated a disproportionate commonality in failure to confirm the correct procedural side (63% of cases).