American Society of Regional Anesthesia and Pain Medicine August 2018 - 26

Peer-Driven Principles Promote Correct-Site Nerve Blocks
OVERVIEW
Wrong-site nerve blocks (WSBs) comprise nearly 26% of all wrongsite procedures reported in Pennsylvania since 2004. To address
their frequency, the Pennsylvania Society of Anesthesiologists and
Pennsylvania Patient Safety Authority joined forces to review the
literature and consider Pennsylvania health care facilities' current
prevention practices. With the assistance of a multidisciplinary task
force, 21 principles emerged reflecting clinical, environmental, and
cultural practices to prevent WSBs.
DATA DEFINE THE PROBLEM
The Pennsylvania Patient Safety Authority (authority) has tracked
reports of wrong-site procedures through the Pennsylvania Patient
Safety Reporting System (PA-PSRS) since 2004.*
Of all the wrong-site procedures identified between July 2004
and September 2017, nearly 26% were WSBs administered by
anesthesiologists or surgeons.
In a systematic literature review, Deutsch et al2 noted that the
incidence of WSB from four publications reporting at least 10,000
patients ranged from 0.52 to 5.07 per 10,000 blocks, unilateral
blocks, or at-risk procedures. In one of the publications, Hudson
et al,3 from the University of Pittsburgh, determined that the
prevalence of WSB was 1.28 per 10,000 unilateral procedures
between 2003 and 2012 and that the organization's prevalence of
WSB was 10 times higher than that of wrong-site surgery between
2009 and 2012 (Figure 1).
Partnership Addresses Common Goal. In response to what
appeared to be a slower adoption of wrong-site prevention
practices by anesthesiologists in perioperative or pain
services than by surgical teams, the Pennsylvania Society of
Anesthesiologists (society) and authority partnered in 2015
to help Pennsylvania physicians and health care facilities
implement a set of clinical, organizational, and cultural
approaches to prevent WSBs. The initiative focused on
perioperative nerve blocks performed by anesthesiologists on
the day of surgery and excluded both local anesthetic infiltration
or peripheral nerve blocks administered by surgeons as part of a
surgical procedure and nerve blocks performed for chronic pain
management.

Donald E. Martin, MD
Professor Emeritus of Anesthesiology
and Perioperative Medicine
Pennsylvania State University
College of Medicine
Hershey, Pennsylvania
Pennsylvania Society of
Anesthesiologists
Harrisburg, Pennsylvania

Figure 1: Prevalence of wrong-site surgery versus wrong-site blocks,
fiscal years 2009-2012.
* P < .05. From Hudson ME, Chelly JE, Lichter JR. Wrong-site nerve blocks:
10 yr experience in a large multihospital health-care system. Br J Anaesth.
2015;114(5):818-824. Reprinted with permission.

To obtain a broad perspective of the contributing factors, morbidity,
and potential strategies for preventing WSBs, representatives
from the authority and society performed a systematic review
of the English-language world literature.2 In the 70 publications

* PA-PSRS is a secure, web-based system that permits medical facilities
to submit reports of serious events and incidents involving patients, as
defined by the Medical Care Availability and Reduction of Error Act.1

Theresa V. Arnold, DPM
Manager, Clinical Analysis
Pennsylvania Patient Safety Authority
Harrisburg, Pennsylvania

American Society of Regional Anesthesia and Pain Medicine
2018

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2018