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Characterizing Novice Behavior Associated With Learning Ultrasound-Guided Peripheral Regional Anesthesia
  1. Brian D. Sites, M.D.,
  2. Brian C. Spence, M.D.,
  3. John D. Gallagher, M.D.,
  4. Christopher W. Wiley, M.D.,
  5. Marc L. Bertrand, M.D. and
  6. George T. Blike, M.D.
  1. Department of Anesthesiology, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, NH
  2. Department of Orthopedic Surgery, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
  1. Reprint requests: Brian D. Sites, M.D., Dartmouth-Hitchcock Medical Center. One Medical Center Drive, Lebanon, NH 03756. E-mail: brian.sites{at}


Background and Objectives: Ultrasound-guided regional anesthesia is a rapidly growing field. There exists little information regarding the competencies involved with such a practice. The objective of this exploratory study was to characterize the behavior of novices as they undertook the challenges of learning a new technique. In addition to assessing for both committed errors and accuracy, we aimed to identify previously unrecognized quality-compromising behaviors that could help structure effective training interventions.

Methods: By using detailed video analyses, the performances of 6 anesthesia residents were evaluated while on a dedicated 1-month rotation in ultrasound-guided regional anesthesia. From these video reviews, we assessed accuracy, errors committed, performance times, and searched for previously unrecognized quality-compromising behaviors.

Results: A total of 520 nerve blocks were videotaped and reviewed. All residents performed at least 66 nerve blocks, with an overall success rate of 93.6% and 4 complications. Both speed and accuracy improved throughout the rotation. There were a total of 398 errors committed, with the 2 most common errors consisting of the failure to visualize the needle before advancement and unintentional probe movement. Five quality-compromising patterns of behavior were identified: (1) failure to recognize the maldistribution of local anesthesia, (2) failure to recognize an intramuscular location of the needle tip before injection, (3) fatigue, (4) failure to correctly correlate the sidedness of the patient with the sidedness of the ultrasound image, and (5) poor choice of needle-insertion site and angle with respect to the probe preventing accurate needle visualization.

Conclusions: Based on the analysis of the committed errors and the identification of quality-compromising behaviors, we are able to recommend important targets for learning in future training and simulation programs.

  • Ultrasound
  • Regional anesthesia
  • Education
  • Training
  • Nerve blocks

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  • Funded by a grant from the Foundation for Anesthesia, Education, and Research (FAER).