American Society of Regional Anesthesia and Pain Medicine August 2018 - 28
"Although professional organizations have previously published
recommendations for preventing wrong-site procedures, including
those specific to nerve blocks, the consensus-based, peer-driven
21 principles resulting from this collaboration are unique
compared with other guidelines and statements."
reviewed, they identified the following 5 common themes as
contributing to WSBs:
1. Time pressure (eg, case volume, time required for additional
safety steps, production demand, pressure from patients)
2. Personnel factors (eg, changes in personnel, novice care
providers, cognitive error, apraxia, reliance on memory,
incompetence, complacency, fatigue)
3. Site mark not visible (eg, block mark not done, block mark
smeared, surgical mark not visible during nerve block or not
done)
4. Distraction (eg, interruption, teaching, time delay, running two
rooms, intervening procedures)
5. Inadequate communication (eg, language barriers;
inadequate documentation; missing, inconsistent, or incorrect
documentation; lack of surgical consent; use of abbreviations)
The collaborative team also engaged a multidisciplinary task force
of 11 anesthesiologists: 9 with expertise in perioperative nerve
blocks and 2 consultants, 4 surgeons, 3 pain service nurses, and
2 patient representatives. The task force represented 10 academic
and private health care centers in Pennsylvania.
Each task force member participated in a structured interview with
the collaborative team to discuss potential WSB risk factors and
their respective facility's prevention techniques. The systematic
literature review and task force interviews yielded 66 clinical,
organizational, and cultural practices for preventing WSB. Of those,
53 pertained to care processes before, during, and after nerve
block administration. The remaining 13 practices pertained to the
environment of a health care facility's structure and culture of
safety.
Principles Promote Prevention. The collaborative team collated
the 66 WSB prevention practices and used them to develop a
survey. The task force members reviewed the practices and
rated their level of agreement with each practice's potential for
preventing WSB using a five-point scale (ie, strongly agree, agree,
neutral, disagree, and strongly disagree). The task force achieved
consensus regarding the practices during two meetings and
unanimously approved a final set of 21 principles. The Principles
28
for Reliable Performance of Correct-Site Nerve Blocks proposed 12
Process of Care practices and 9 Health Care Facility Structure and
Culture of Safety practices (Figure 2).
Although professional organizations have previously published
recommendations for preventing wrong-site procedures, including
those specific to nerve blocks,4-7 the consensus-based, peer-driven
21 principles resulting from this collaboration are unique compared
with other guidelines and statements. The principles:
* Demonstrate a successful collaborative partnership between a
medical professional society and an independent state agency.
* Take advantage of the diverse training, culture, and
perspectives of a multidisciplinary task force that included
patients, pain service nurses, surgeons, and anesthesiologists.
* Reflect data from a robust state-based event reporting system
(ie, PA-PSRS) that demonstrated the continued prevalence of
WSB in clinical practice.
* Use primary and confirmatory preoperative data sources,
including patients, to verify the exact location and laterality of
the surgical site.
* Describe specific site-marking and time-out procedures based
on needs identified in past or current practice.
* Consider the unique environment and culture in which nerve
blocks are performed to promote successful implementation
and sustainability of clinical processes.
SUMMARY
WSBs accounted for about one-quarter of all wrong-site procedures
reported to PA-PSRS between July 2004 and September 2017. In
an attempt to reduce their incidence, the society and the authority
identified a set of 21 principles-12 related to clinical practices
and 9 specific to environmental and cultural improvements-
to help facilities sustain and implement the clinical practices.
Anesthesiologists are encouraged to review the peer-driven
principles and work with their health care organizations to
incorporate them as standard surgical-safety practices.
REFERENCES
1.
Pennsylvania Patient Safety Authority. 2016 Pennsylvania Patient Safety
Authority Annual Report. Harrisburg, Pennsylvania: Pennsylvania Patient Safety
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
American Society of Regional Anesthesia and Pain Medicine August 2018 - 1
American Society of Regional Anesthesia and Pain Medicine August 2018 - 2
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