Although not as sensational or disastrous as wrong-site surgeries, wrong-site peripheral nerve blocks are potentially dangerous, and according to a 10-year analysis by Pittsburgh researchers, 10 times more common than their surgical counterparts. Yet the problem can be largely—if not entirely—avoided with better planning, vigilance and engagement by the various members of the care team.
“Our department instituted a standardized policy with mandatory training and process audits regarding wrong-site blocks in June 2010,” said Mark Hudson, MD, MBA, associate professor of anesthesiology and vice chair for clinical operations at the University of Pittsburgh Medical Center (UPMC). “And it’s interesting that they continued to occur even after we tried to implement stops to prevent them. So just having a policy in place, no matter how robust it may be, doesn’t completely eliminate wrong-site blocks, because it relies on people following the policy.”
Dr. Hudson and his colleagues used quality improvement and billing data to determine the number of wrong-site blocks between July 2002 and June 2012 within the UPMC system. Between 2002 and 2010, each hospital was responsible for verification processes concerning nerve blocks. Following a wrong-site block in June 2010, a mandatory time-out policy was developed. This evolved in March 2011 to a system-wide policy, which was approved and introduced across all system hospitals. All but one hospital performed blocks in a preoperative holding area.
UPMC clinicians performed 169,508 blocks on 85,915 patients across the system during the study period. Nine wrong-site blocks occurred, for an incidence of 1.05 per 10,000 patients. The incidence of wrong-site blocks varied from none to three per year and none to three per location. As the investigators reported at the 2013 annual meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract A20), five of the nine wrong-site blocks were femoral, two were lumbar plexus, one interscalene and one cervical.
“In looking at facilities, we examined sites with and without dedicated acute interventional pain programs,” Dr. Hudson told Anesthesiology News. When a member of the anesthesiology team rather than the dedicated interventional pain team performed the procedure, the frequency of wrong-site blocks nearly doubled.
Although wrong-site blocks were recorded after the development of various policies, the incidence fell to about half its previous rate. Furthermore, review of these post-policy cases revealed that in each instance, the care team did not follow approved policy. In one case, the team that performed the block differed from the team that performed the time-out. In the second case, the time-out was performed before the patient was positioned and marked. And in the most recent case, the patient’s marking was not visible when the block was performed.
Yet for Dr. Hudson, perhaps the study’s most disturbing finding came when he compared the incidence of wrong-site blocks with wrong-site surgeries (for which data were available for the past four years): Wrong-site blocks outnumbered wrong-site surgeries by a factor of 10.
“I think there has been so much attention paid to wrong-site surgeries that now there are clearly defined policies and roles within that policy for the surgical team,” he explained. “That’s not necessarily the case for the block team.”
And although the consequences may not be as serious for wrong-site blocks as they are for wrong-site surgery, that does not mean they should be taken lightly. “I think any time a procedure is done on the wrong side, there’s a risk associated with it,” Dr. Hudson said. “Either way, this should be a zero event. It should never happen.”
Stephen M. Rupp, MD, medical director of perioperative services at Virginia Mason Medical Center, in Seattle, noted that preventing wrong-site blocks goes well beyond simply creating new policies. “This is more about training and culture,” Dr. Rupp said. “So you need the key opinion leaders in the department to speak up and say, ‘We’re going to do this.’ Once you’ve made that commitment, you need a poster visible in the room where the block is performed, to remind people of steps in the process,” Dr. Rupp continued. “Patients love when you create that environment; they love to hear you going through those steps. It’s reassuring to them.”