Wrong-site nerve blocks are 10x more common than wrong-site surgeries — 5 takeaways

Categorized as a "never event," wrong-site nerve blocks have potentially severe consequences and can cause patients harm and distress, according to Anesthesia Business Consultants President and CEO Tony Mira.

Here's what you should know:

1. A 2015 study by Pittsburgh-based UPMC anesthesiologists found a wrong-site nerve block prevalence of 1.28 per 10,000 unilateral procedures between 2003 and 2012. The rate of wrong-site nerve blocks was 1.01 per 10,000 patients, compared to 0.10 per 10,000 patients for wrong-site surgeries.

2. These study findings prompted the Pennsylvania Society of Anesthesiologists and the Pennsylvania Patient Safety Authority to develop a peer-driven protocol targeting wrong-site nerve blocks from clinical, cultural and environmental perspectives.

3. The organizations found five main causes of wrong-site nerve blocks:

  • Time pressure, including production demand
  • Personnel issues, including complacency and fatigue
  • Block site marks not visible or missing
  • Distractions and interruptions
  • Inadequate communication, including language barriers, documentation issues and abbreviation use

4. Based on literature review, interviews and survey results, the task force developed 21 principles for reliable performance of correct-site nerve blocks, including 12 process of care practices and nine healthcare facility structure and care culture practices.

5. The organizations encourage anesthesiologists to implement the principles as standard surgical safety practices. Read about the principles here.

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