Two cases of a wrong-site peripheral nerve block and a process to prevent this complication

Abstract

The anesthesiologist plays an important role in preventing wrong-site peripheral nerve blockade and surgery. The protocol developed for "Pre-Anesthetic Site Verification" as a supplement to our preoperative site verification policy is invaluable in preventing wrong-site anesthesia and surgery.

Wrong-site regional anesthesia

“…The incidence of wrong-site pain procedures is estimated to be 2.66 per (95% confidence interval 1.41-4.54) per 10 000 (13 events in 48,941 procedures) [8]. [9][10][11][12][13][14]. The rarity of published case reports precludes definitive assessment of factors likely to eliminate wrong-site block.…”

“…Smearing of a site mark from the operative to nonoperative side has been reported for a lower limb procedure [24]. Of note, Edmonds et al [9] decided against a separate block site mark to avoid confusion with the surgical site marking. In contrast, Nixon and Wheeler [13] recommended to use the word 'BLOCK' at the block site.…”

“…Delivery of high-quality clinical requires teamwork and lack of physician support has been attributed to failure of existing protocols [9]. A patient safety initiative was introduced at Nottingham University Hospitals, UK in association with the Safe Anaesthesia Liaison Group of the Association of Anaesthetists of Great Britain and Ireland [25].…”

Complications of regional anesthesia

“…In a field proudly featuring exceptional achievements of nerve localization, imaging, nerve stimulation and reductions in mortality and morbidity, it may seem trivial and incongruous to discuss the (seemingly) simple concept of wrong-sided procedures [24]. It is not trivial.…”

Patient safety in the operating theatre: an overview

“…Spinal surgery done at the wrong level 5 Peripheral nerve block performed on the wrong extremity 6 Surgery on the wrong limb or digit 7,8 Extraction of the wrong tooth 9 Kidney removed from the wrong side 10 Operation on the wrong eye 11 Operation on the wrong side of the brain 12 Hernia operation on the wrong side 13 Removal of the wrong breast 14 Chest tube inserted into the wrong side 15 Box 2. 05.edozien.txt.01 8/16/05 12:01 PM Page 2 orthopaedic/podiatric surgery; 20% to general surgery; 14% to neurosurgery; 11% to urological surgery; and the remaining 14% to dental/oral maxillofacial, cardiovascular-thoracic, ear-nose-throat, and ophthalmologic surgery.…”