PRINTER-FRIENDLY VERSION AVAILABLE AT ANESTHESIOLOGYNEWS.

COM

Wrong-Side Nerve Blocks

And the Use of Checklists:
Part 1
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ANGELA LUCIA BALOCCO, MD1 THIBAUT VANNESTE, MD2

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SAMANTHA KRANSINGH, MD1 ASTRID VAN LANTSCHOOT, MD2

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ANA LOPEZ, MD, PHD2 DIMITRI DYLST, MD2

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SAM VAN BOXSTAEL, MD2 QUEENAYDA KROON, MD1

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CATHERINE VANDEPITTE, MD, PHD2 ADMIR HADZIC, MD, PHD2

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1 Dr. Hadzic reported that he is the founder and director of

Regional Anesthesia Fellow Department of Anesthesiology
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2 NYSORA, and an Anesthesiology News editorial advisory

Consultant Anesthesiologist Ziekenhuis Oost-Limburg
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Genk, Belgium board member.

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The other authors reported no relevant financial disclosures.

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T
he available data suggest that wrong-side
nerve blocks may occur as much as 10 times
more often than wrong-site surgeries.

24 A N E ST H E S I O LO GY N E WS .CO M
Background
Checklists have been introduced as a solution for
patient safety and a number of other quality issues
in health care. They are considered to be an inexpen-
sive and simple method to avoid common human
errors, applicable across a wide range of processes.
The recent rise in their utilization and popularity can be
largely attributed to the recommendations from studies
by Gawande et al1,2 and Pronovost et al.3 Also, a 2009
nonfiction book by Gawande, “The Checklist Manifesto:
How to Get Things Right,” is a fascinating read for any-
A
Wrong-Side Nerve Blocks as Sentinel Events
Wrong-side nerve blocks (WSNBs) could be consid-
ered a prototypical example of a sentinel event, akin
to WSS. Of note, WSNBs may occur more commonly
than WSS procedures, and may even increase the risk
for surgery on the wrong site, as the surgical team may
be misled to perform the surgery on the wrong site. As
an example, data from 30 hospitals across Massachu-
setts over a 20-year period determined the incidence
of WSS procedures was one in 112,994.2 In contrast, the
reported incidence of WSNBs in regional anesthesia

one interested in the topic.4 The book describes the

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amazing utility of checklists in daily and professional

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life using a highly practical and illustrative format.

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Although checklists are routinely used in medicine Table 1. Risk Factors Involved in
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to prevent mishaps and errors, continuing publications Wrong-Side Nerve Blocks

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of case reports describing the occurrences of wrong-

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side (also called wrong-site) procedures illustrate that

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Physician Factors
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there is no simple solution to this problem, and that

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High-pressure environment; overbooked list

checklists alone are not a panacea or cure-all solution.
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The checklists in health care are intended specifically Other personal time pressures
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to improve communication and teamwork (e.g., a dis-

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cussion of patient risk factors) and accomplishment of

straightforward categorical checks (e.g., hands washed,
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Multiple team members with no clear hierarchy or

informed consent obtained). However, the “catch-22” is
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accountability
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that the successful completion of the procedure-related

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Poor communication or interpersonal relationships

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checklist requires training in their implementation in a

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multidisciplinary environment. Change of staff during the procedure

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Definitions of Wrong-Side Procedures Failure to mark the site

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The Joint Commission defines wrong-site surgery Failure to check the site
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(WSS) as an invasive procedure performed on the

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wrong part of the body, the wrong side, or in the wrong Poor recording (inappropriate or misinterpreted
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abbreviations)
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patient, and which exposes the patient to more than

minimal risk.5 This definition encompasses procedures
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Patient Factors
performed both in the OR and in patient care settings
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Sedated or confused, or block sited after induction of

outside an OR.6
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anesthesia
The National Quality Forum has labeled wrong-side
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invasive procedures as a “never event,” meaning they Similar patient names

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should never occur. Consequently, considerable time

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Language/communication difficulties
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and effort have been expended to prevent WSS, result-

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ing in the institution of a number of initiatives and poli- Abnormal anatomy

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cies, including the enactment of the Universal Protocol

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Multiple blocks needed in the same patient

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by the Joint Commission in 2004.7

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Every WSS is considered a sentinel event, defined

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Hemodynamic instability causing distraction and time

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as a serious adverse patient safety situation, not pri- pressure

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marily related to the natural course of the patient’s ill-

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Procedural Factors
ness or underlying condition.6 Sentinel events require
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institutional root cause analysis, the identification of a Change in patient position

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remedy, and reporting to appropriate regulatory agen-

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Change in the OR or procedural environment

cies. The root cause analysis is an essential part of the
Joint Commission’s institutional accreditation and/or Changes in the order of operating list
reaccreditation review. The institution typically uses
the facts from the root cause analysis to modify exist- Wrong site marked
ing policy to incorporate additional layers of patient Mark erased or covered
protection and replace the policy that failed. However,
when the root cause analysis determines that the prac- Distractions (phone calls, verbal, staff teaching, entry
of other staff, alarms)
titioners omitted or failed to follow the checklist, the
practitioners may be subject to disciplinary action.

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 0 1 9 25
ranges from 1.28 to 3.63 per 10,000 procedures (i.e.,
1/2,755-1/7,812).8 Therefore, the available data sug-
gest that WSNBs may occur as much as 10 times more
often than WSS. Moreover, the real-life incidences of
WSS and WSNBs are probably much higher, due to
underreporting.
Risk Factors for Blocks on the Wrong Side
Factors involved in the occurrence of WSNBs can be
classified as procedural, physician- and patient-related
factors (Table 1). Nerve blocks are usually unilateral,
and often require a change of patient position from
that in which the checklist was performed. This change

Table 2. Published Case Reports of Wrong-Side Nerve Blocks and the Circumstances

Authors Cases Wrong-Side Block Type of Surgery Risk Factor

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Nixon H, et al15 1 Femoral nerve block Knee surgery Procedural (change in position)
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Petrova E, et al16 1 Iliofascial block Femoral neck fracture Patient

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Procedural
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Al-Nasser B17 1 Continuous popliteal sciatic Hallux valgus repair Patient

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nerve block Procedural

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Edmonds C, et al18 2 (1) Interscalene block (1) Humerus fracture Physician

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(1) Psoas block (1) Hip revision Procedural

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Barrington MJ, et al19 1 Paravertebral block Multiple rib fractures Physician

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Henshaw DS, et al 4 (2) Combined femoral (2) Knee arthroplasty Information not provided
catheter + sciatic nerve block
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(1) Drainage of a foot

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(1) Ankle block wound

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(1) Not specified (1) Not specified

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Fox M, et al21 4 (2) Brachial plexus block Information not provided Information not provided
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(2) Ophthalmic block

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Stanton MA, et al22 2 (1) Femoral nerve block (1) Total knee arthroplasty Physician
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(1) Femoral catheter (1) Total knee arthroplasty Patient

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O’Neill T, et al23 1 Peribulbar block Cataract extraction for Physician

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moderate nuclear sclerosis Patient

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Simmons H, et al24 2 (1) Interscalene block (1) Biceps tendon repair Physician
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(1) Femoral + sciatic block (1) Total knee arthroplasty Patient

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Hudson M, et al25 9 (6) Femoral nerve block Information not provided Physician
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(1) Interscalene block

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(1) Cervical plexus block

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(1) Lumbar plexus block

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Clarke JR, et al26 39 Information not provided Information not provided Information not provided
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LaReau JM, et al27 1 Femoral nerve block Information not provided Information not provided
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Cohen SP, et al28 13 (1) Lumbar sympathetic block Information not provided Physician
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(9) Pain procedures Procedural

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(1) Suprascapular Patient

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(2) Intercostal
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Yeoh MF, et al29 2 Information not provided Information not provided Information not provided
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James M, et al30 2 Information not provided Information not provided Information not provided
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Seiden SC, et al 3 Information not provided Information not provided Information not provided
Fox M, et al32 4 (2) Brachial plexus blocks Information not provided Information not provided
(2) Local infiltrations
Simon J, et al33 14 Ophthalmic block Information not provided Physician
Patient
Sites B, et al11 7 Information not provided Information not provided Information not provided

26 A N E ST H E S I O LO GY N E WS .CO M
 in position for performance of the block may lead to a
higher risk for WSNBs. As an example, for a popliteal
block, the patient’s informed consent and confirma-
tion on the site of surgery, as per the checklist, are usu-
ally obtained with the patient in the supine position.
Subsequently, the patient may then be repositioned
into the lateral or prone position, possibly resulting in
a confusion in laterality at the point of care. A descrip-
tion of the circumstances that were determined to
contribute to the occurrences of WSNBs is featured
in Table 2, which lists published case reports of blocks
placed on the wrong side.

Under Which They Occurred

Correct-Side
Circumstances Block Performed?
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Wrong-side femoral nerve block was performed after patient repositioning (from prone to supine) Yes
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• Difficult interrogation due to history of dementia No

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• Block side not written in file

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• Block performed under general anesthesia

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• No previous time-out
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• The side to block was confirmed with sedated patient Yes

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• Time-out performed after the block and general anesthesia (preventing only wrong surgical side)
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• Members of the perioperative team were distracted during the procedure (1) No
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• OR setting prepared for wrong side (1) Yes

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• Surgical team identified wrong-side extremity was prepared

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The routine safety check was not performed before the procedure Yes
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• Attending anesthesiologist was not present for the time-out Not specified
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• The patient for ankle block had wounds on both feet, which potentially contributed to the error
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• No time-out was performed prior to procedures

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Information not provided Not specified

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• Site verification prior to the block was not performed Yes

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• Site verification was performed only with the patient

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• Surgeon referral letter didn’t specify the site of surgery Yes

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• Wrong side written on patient’s pre-assessment questionnaire

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• Block performed during general anesthesia (1) No

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• Wrong side was prepared and blocked (1) Yes

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• Surgical side was confirmed by the anesthesiologist only with the patient
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• Site marking was noticed (correct side) after the block was already performed on wrong side
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• The attending physician who performed the block did not participate in the time-out Not specified
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• Personnel responsible for time-out felt rushed through the process

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• Correct location was not marked on the patient

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• The anesthetist did not see the marking on the femoral site after the patient had been repositioned
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Information not provided Not specified

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Information not provided Not specified

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• No time-out Not specified

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• Wrong side prepared

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• Side not confirmed with the patient

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• Poor communication within surgical team

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Information not provided Not specified

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Information not provided Not specified

Information not provided; pain procedures Not specified
Information not provided Not specified

• No site marking indicating the correct eye for operation Not specified
• Patient indicated the wrong side
Information not provided Not specified

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 0 1 9 27
Prevention of WSNBs
Organized societies of anesthesiologists have pro-
vided recommendations for the prevention of wrong-
side procedures. As an example, the American Society
of Regional Anesthesia and Pain Medicine appointed a
task force to publish recommendations for a prepro-
cedural checklist specific to regional anesthesia.9 The
use of a checklist before surgical procedures has been
demonstrated to positively affect surgical outcomes,
including mortality,10 but the utility of a preprocedural
checklist in decreasing the risk for WSNBs has not been
A
in industry (e.g., the aviation industry) may not be
realistic. An example of a checklist used in the aviation
industry is shown in Figure 1. One fundamental
difference between the aviation industry and patient
care is that the latter requires multiple teams, as
opposed to the checklist used in a cockpit of an
aircraft that involves small teams, typically consisting
of just the pilot and co-pilot. Of note, checklists that
rely on teamwork for success may fail despite all the
items being followed, because of the potential lack
of team skills.12 Therefore, simply implementing and

formally established—although logic should lead one to enforcing checklists, and strict progression through
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believe that it should be beneficial.11 the items in them, may not necessarily yield benefits
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In a commentary, Catchpole and Russ pointed out to the overall outcome.

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that a limitation of team-related checklists is the lack

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of a single calm moment where all team members can

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be involved.12 Consequently, not all users may derive

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the same benefit from the checklists, despite the effort

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and initiative required for their use. Complex socio-

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logical and cultural challenges, such as hierarchy and

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perceptions of professionalism, also may interfere with

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interactions, regardless of the design and implemen-

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tation of the checklists. Introducing a checklist with-

out consideration of these processes carries a risk
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for neglecting the sociocultural underpinnings of the

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intervention and complexity of coordinating a complex

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team around a single task.12

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Thus, the expectation that the application of

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checklists in health care will have the same result as

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Figure 2. An example of labeling the

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site of the block and consequent

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surgery with an arrow.

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Figure 3. An example of labeling

Figure 1. An example of a checklist the “correct” site of surgery with a
used in the aviation industry. sticker, “block.”

28 A N E ST H E S I O LO GY N E WS .CO M
 One of the difficulties with the use of checklists, access patient management protocols and download
which have been adopted nearly universally in all the latest nerve block techniques and illustrations
aspects of patient care, is that their routine application from NYSORA’s all-new regional anesthesia app
at multiple points in patient pathways has created (Figure 5).
checklist weariness, and potentially decreased their
value in enhancing patient safety. Moreover, while
the use of a checklist is mandated throughout most
surgical facilities in the developed world, the policies
on how they must be implemented and method of
labeling the correct site vary substantially.
In some institutions, the site of the surgery
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and nerve block is labeled with a skin marker as

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“yes” or an arrow (Figure 2), or “block” (Figure 3),

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whereas others label the “wrong side” with a “no”

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(Figure 4).13 For instance, the current policy at Duke

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University provides secondary verification through

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an anesthesiologist’s marking of the block side(s).

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This is because patient repositioning for the block

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may hinder surgical marking visibility, and placing

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an additional marking provides a more reliable visual

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cue to the practitioner, regardless of the presence

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of the patient’s gowns, blankets or positioning.13

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This additional marking helped practitioners at Duke

University avoid a near-miss of placing a wrong-
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side peripheral nerve catheter because of an unusual

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transfer of the surgical mark. The ability to verify

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Figure 4. An example of labeling

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the single-shot block site meant the procedure was

the “wrong” site of surgery with a
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performed on the correct extremity.13 No data exist to

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provide any meaningful guidance as to which method sticker, “no.”

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of applying indicia is optimal.

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The variability of checklist implementation at the

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point of care is so large among institutions that no

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standards exist, and despite the checklists, WSNBs

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continue to occur. Another difficulty with the role of

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checklists in the prevention of WSNBs is that they are

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notoriously difficult to implement and enforce at the

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point of care. As an example, during a performance of

a peripheral nerve block procedure, it is possible that
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after the checklist and time-out process have taken

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place, the anesthesia provider could be distracted

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or interrupted to assist in patient care at another

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location. Upon returning to the task of performing

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the nerve block, the provider may not fully recollect

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the laterality from the checklist, which appears to be

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a common scenario in reports of WSNB occurrences.

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These and other descriptions of mishaps and near-

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mishaps underscore the importance of implementing

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protocols with additional layers of redundancy. In

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support of the need for redundancy, Pandit et al, in

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their letter to the editor titled, “’Mock Before You

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Block’: An In-Built Action-Check to Prevent Wrong-

Side Anaesthetic Nerve Blocks,” cogently suggested
that some type of reminder be built into the action Figure 5. To access the app, type
itself in order to be effective.14 The NYSORA team
has been collaborating with international opinion
“NYSORA app” in your web browser
leaders in regional anesthesia to develop a universally for descriptions of regional
applicable solution to this longtime industry problem, anesthesia and pain medicine
which will be discussed in the next part of this article, techniques.
to be published in 2020. Visit app.nysora.com to

A N E ST H E S I O LO GY N E WS S P E C I A L E D I T I O N 2 0 1 9 29
References
1. Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for 18. Edmonds CR, Liguori GA, Stanton MA. Two cases of a wrong-site
retained instruments and sponges after surgery. N Engl J Med. peripheral nerve block and a process to prevent this complication.
2003;348(3):229-235. Reg Anesth Pain Med. 2005;30(1):99-103.

2. Kwaan MR, Studdert DM, Zinner MJ, et al. Incidence, patterns, and 19. Barrington MJ, Uda Y. Wrong-side bedside paravertebral block:
prevention of wrong-site surgery. Arch Surg. 2019;141(4):353-357. preventing the preventable. AORN J. 2018;108(4):480-482.

3. Pronovost P, Needham D, Berenholtz S, et al. An intervention

20. Henshaw DS, Turner JD, Dobson SW, et al. Preprocedural checklist
to decrease catheter-related bloodstream infections in the ICU.
for regional anesthesia: impact on the incidence of wrong-site
N Engl J Med. 2006;355(26):2725-2732.
nerve blockade (an 8-year perspective). Reg Anesth Pain Med.
2019;44(2):201-205.
4. Gawande A. The Checklist Manifesto: How to Get Things Right.
A

New York, NY: Metropolitan Books; 2010.

21. Fox M, Morris RW, Runciman WB, et al. Crisis management during
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regional anaesthesia. Qual Saf Health Care. 2005;14(3):e24.

rig

5. Fraser SG, Adams W. Wrong-site surgery. Br J Ophthalmol.

Co

2006;90(7):814-816.
ht

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22. Stanton MA, Tong-Ngork S, Liguori GA, et al. A new approach

s

6. The Joint Commission. Sentinel events. In: Comprehensive to preanesthetic site verification after 2 cases of wrong site
rig ed.
re

Accreditation Manual for Hospitals. www.jointcommission.org/ peripheral nerve blocks. Reg Anesth Pain Med. 2008;33(2):174-177.
ht
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assets/1/6/CAMH_SE_0717.pdf. Update 1, July 1, 2017. Accessed

September 2, 2019. 23. O’Neill T, Cherreau P, Bouaziz H. Patient safety in regional
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anesthesia: preventing wrong-site peripheral nerve block. J Clin

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7. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic Anesth. 2010;22(1):74-77.
review of impacts and implementation. BMJ Qual Saf.
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2014;23(4):299-318. 24. Simmons H, Brits R. Survey of wrong site regional anaesthetics.

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Dep Anaesth East Lancash Hosp NHS Trust 2011;16:1-8.

8. Barrington MJ, Uda Y, Pattullo SJ, et al. Wrong-site regional
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anesthesia: Review and recommendations for prevention? Curr

25. Hudson ME, Chelly JE, Lichter JR. Wrong-site nerve blocks:
Opin Anaesthesiol. 2015;28(6):670-684.
uc

ah in w

10 yr experience in a large multihospital health-care system.

tio

Br J Anaesth. 2015;114(5):818-824.
on

9. Mulroy MF, Weller RS, Liguori GA. A checklist for performing

regional nerve blocks. Reg Anesth Pain Med. 2014;39(3):195-199.
n

Pu

26. Clarke JR, Johnston J, Finley ED. Getting surgery right. Ann Surg.
2007;246(3):395-403.
10. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist
bl

to reduce morbidity and mortality in a global population. N Engl J

is
ho

Med. 2009;360:491-499. 27. LaReau JM, Robbins CE, Talmo CT, et al. Complications of femoral
hi

nerve blockade in total knee arthroplasty and strategies to reduce

ng
le

11. Sites B, Barrington M, Davis M. Using an international clinical patient risk. J Arthroplasty. 2012;27(4):564-568.
or

registry of regional anesthesia to identify targets for quality

G

improvement. Reg Anesth Pain Med. 2014;39(6):487-495. 28. Cohen SP, Hayek SM, Datta S, et al. Incidence and root cause
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analysis of wrong-site pain management procedures: a

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12. Catchpole K, Russ S. The problem with checklists. BMJ Qual Saf. multicenter study. Anesthesiology. 2010;112(3):711-718.
2015;24(9):545-549.
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29. Yeoh MF, Macfarlane A. Completing the stop before you block
w

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13. Yalamuri S, Gadsden J. Wrong-sided nerve block—a close prior to performing peripheral nerve blocks in a tertiary hospital.
ith

encounter. Presented at: 41st Annual Regional Anesthesiology

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Presented at: 34th Annual European Society of Regional

and Acute Pain Medicine Meeting; March 31-April 2, 2016; New Anaesthesia & Pain Therapy (ESRA) Congress; September 2-5,
ot

Orleans, LA. Abstract 1576. 2015; Ljubljana, Slovenia. Abstract 0178.

he
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14. Pandit JJ, Matthews J, Pandit M. “Mock before you block”: an

rw

30. James MA, Seiler JG, Harrast JJ, et al. The occurrence of wrong-
er

in-built action-check to prevent wrong-side anaesthetic nerve site surgery self-reported by candidates for certification by the
blocks. Anaesthesia. 2017;72(2):150-155.
is
m

American Board of Orthopaedic Surgery. J Bone Joint Surg Am.

e
is

2012;94(1):1-12.
no

15. Nixon HC, Wheeler P. Wrong-site lower extremity peripheral nerve

si

block: process changes to improve patient safety. Int Anesthesiol

on

te

Clin. 2011;49(2):116-124. 31. Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure,

and wrong-patient adverse events. Arch Surg. 2019;141(9):931-939.
d.
is

16. Petrova E, Brasseur F, Benhamou D. Erreur de côté d’un bloc

pr

iliofascial pour une fracture du col fémoral. Ann Fr Anesth Reanim. 32. Fox MAL, Webb RK, Singleton R, et al. Problems with regional
oh

2010;29:796-798. anaesthesia: an analysis of 2000 incident reports. Anaesth

Intensive Care. 1993;21:646-649.
ib

17. Al-Nasser B. Unintentional side error for continuous sciatic

ite

nerve block at the popliteal fossa. Acta Anaesthesiol Belg. 33. Simon JW, Ngo Y, Khan S, et al. Surgical confusions in
d.

2011;62(4):213-215. ophthalmology. Arch Ophthalmol. 2007;125(11):1515-1522.

30 A N E ST H E S I O LO GY N E WS .CO M
Additional References
Barrington MJ, Sites BD. Rare event research: is it worth it?
Br J Anaesth. 2015;114(5):726-727. Chikkabbaiah V, French J, Townsley
P, et al. Further reducing the risk of wrong site block. Anaesthesia.
2015;70:1453.
Management H, Computing M, Working T. Site marking by
anaesthetists preparing for peripheral nerve blockade. Anaesthesia.
2010;65(3):306-315.

Deutsch ES, Yonash RA, Martin DE, et al. Wrong-site nerve blocks:
a systematic literature review to guide principles for prevention.
J Clin Anesth. 2018;46:101-111.
Harris B, Torlot K. Site marking for peripheral nerve blockade
to reduce the incidence of incorrect side regional anaesthesia.
Anaesthesia. 2009;64(9):1022-1036.
A
McLellan EJ, Hade AD, Pelecanos A, et al. Introduction of a mandatory
pre-block safety checklist into a regional anaesthesia block room
service: a quality improvement project. Anaesth Intensive Care.
2018;46(5):504-509.
Rupp SM. Unintentional wrong-sided peripheral nerve block.

Reg Anesth Pain Med. 2008;33(2):95-97.

ll

Kamath P, Stimpson J, Steel A. Wrong-side nerve blocks can be

rig

avoided. Reg Anesth Pain Med. 2015;40(2):176-177.

Co

Slocombe P, Pattullo S. A site check prior to regional anaesthesia

ht

py

Lie J, Letheren M. “Wrong side” sticker/dressing to help reduce to prevent wrong-sided blocks. Anaesth Intensive Care.
s

wrong-sided nerve blocks. Reg Anesth Pain Med. 2014;39(5):441-442.

rig ed.

2016;44(4):513-516.
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