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Poster displayed – Peripheral nerve blocks
P063 Enhancing patient safety in regional anesthesia: lessons learned from wrong-side block events
  1. Ana Larissa Guerrero1,
  2. Mohammad Misurati1,
  3. Deepti Vissa1,
  4. Rodrigo Monteiro Da Silva1,
  5. Kevin Armstrong1 and
  6. Rahul Motwani2
  1. 1Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada
  2. 2Anesthesiology, Guthrie Robert Packer Hospital, Pennsylvania, USA

Abstract

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)

Background and Aims Wrong-side blocks (WSBs) are a rare but serious complication in regional anesthesia. Anesthesia providers at our institution performed an average of 5,000 regional blocks annually across four block rooms. Acknowledging the grave repercussions of inadvertent WSBs, this quality improvement project focuses on investigating contributing factors and proposes preventive strategies, aiming to enhance patient safety.

Methods An anonymous survey assessed WSB occurrences and near-miss events within our institution over the past three years. We analyzed the data to identify potential root causes.

Results Despite safety protocols, four WSBs occurred, all deemed avoidable. Time pressure (32%), increased time between checklist and block (20%), change of assisting nurse (20%), checklist by another person (16%), and change of block performer (12%) were identified as contributing factors. Notably, one WSB resulted from unfamiliar prone positioning practices affecting landmark and ultrasound usage.

Conclusions Factors such as time constraints, communication breakdowns, and procedural variations potentially contribute to the risk of WSB incidents. To mitigate these, we advocate for the implementation of a standardized safety checklist, documented electronically. It is imperative to allocate sufficient time for each procedural block to alleviate time constraints. Additionally, improving communication through handoff protocols and reducing the duration between checklist completion and block execution is paramount. Furthermore, comprehensive WSB prevention training should be imparted to all block room members. These strategies are designed to minimize the occurrence of WSB incidents and optimize patient safety.

Abstract P063 Figure 1
Abstract P063 Figure 1

LHSC Regional Anesthesia Checklist

Abstract P063 Figure 2
Abstract P063 Figure 2

Survey among anesthestists list the following reasons that could lead to a wrong-side block

Abstract P063 Figure 3
Abstract P063 Figure 3

Example of possible human errors leading to wrong-side block

  • Wrong-side blocks
  • regional anesthesia
  • peripheral nerve blocks
  • patient safety
  • safety checklist

https://doi.org/10.1136/rapm-2024-ESRA.456

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