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B115 A sticky end to wrong-sided blocks: a quality improvement project to reduce the incidence of wrong-sided peripheral nerve blocks
  1. H Evans,
  2. A Gilfedder and
  3. A Kennedy
  1. University Hospital of Wales, Cardiff, UK


Background and Aims The incidence of wrong sided blocks is approximately 1 in 6250 procedures1. It has remained unchanged despite high profile national patient safety campaigns, such as Stop Before You Block, as well as wrong-sided blocks being added to the NHS Never Events list. At our institution, we have had two such incidents in the past two years.

A new standard operating procedure – Prep, Stop, Block – is based on the deconstruction of regional anaesthetic procedures into three distinct phases2.

Our aim was to increase awareness and utilisation of the new standard operating procedure at our institution.

Methods We designed a sticker system which worked simultaneously as a visual aide memoir to remind practitioners to perform Prep, Stop, Block as well as a simple, fast and effective method of documenting the performance of both the safety check and the block itself. We recorded use of the stickers over three separate weeks, with each week preceded by an intervention to increase their utilisation.

Results Following two Plan Do Study Act rounds, we increased weekly use of the sticker system from 0 to 53.

Conclusions We have successfully devised a method of increasing utilisation of the Stop, Prep, Block standard operating procedure while simultaneously providing a simple, fast, and effective means of documenting both the safety check and the block itself. The sticker system has made a positive contribution to the safety culture of our institution, forming a visual reminder of the organisation’s commitment to and confidence in the efficacy of preventative measures.

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