| Environmental factors | Human factors | Surgical site-related | Technical factors |
| Distraction in the anaesthetic room | Change of personnel | Lack of mark | Delay/prolonged time between WHO sign in & block performance |
| Social activity in the anaesthetic room | Change of operating list order | Mark obscured e.g. by blankets | ↑ distance between block site & surgical site |
| Block performed outside theatre complex | Operator performs blocks less regularly (more junior, locums) |
Patient prone or otherwise re-positioned | Lower limb blocks |
| Stress, rushing due to time pressure | Patient already anaesthetised | >1 block being performed | |
| Human error | No SBYB undertaken |
Wrong-Sided Block
Wrong-Sided Block
This never event appeared as an SAQ in 2017, with marks evenly split between contributory factors, patient sequelae, SBYB recommendations and other types of drug-related never event.
It re-appeared as an SAQ in 2019 (pass rate 57%); once again there were marks for factors contibuting to wrong-sided block and for other never events.
Resources
- Stop Before You Block (Safe Anaesthesia Liaison Group, 2018)
- Stop Before You Block Campaign (NHS England Safe Anaesthesia Liaison Group & RA-UK, 2020)
- Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system (BJA, 2015)
- Working out wrong-side blocks (Anaesthesia, 2017)
- Best practices for safety and quality in peripheral regional anaesthesia (BJA Education, 2020)
- Wrong-sided nerve block is a never event:
A serious, preventable patient safety incident that should not occur if the available preventative measures have been implemented
- The estimated incidence is 0.5 - 5 per 10,000 blocks
- In the above-linked BJA study the overall incidence over 10yrs was 1.05 per 10,000 blocks
- WHO sign in at start i.e. confirm patient identity, consent and marked surgical site
- Subsequent two - person check, immediately before needle insertion, of:
- Surgical site marking arrow
- Confirmation of side of block
- Either confirmed with the patient if they're awake
- Or confirmed with the consent form if they're already anaesthetised
- Nerve injury
- LA toxicity
- Wrong-site surgery
- Delayed start to surgery
- Delayed hospital discharge due to reduced mobility or dexterity
- Patient dissatisfaction and/or distrust