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Prevention of Wrong-Side Nerve Blocks: Part 2

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VINCENT VANDEBERGH, MD1

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VICTOR COLL2
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escriptions of mishaps and
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BRAM KEUNEN, MD3

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near-mishaps underscore the

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1. Anesthesiology resident, University of Antwerp,

importance of implementing
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Antwerp, Belgium
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2. Research assistant, North Central College, Naperville, Ill.

3. Anesthesiology resident, KUL Leuven, Leuven, Belgium
protocols with additional layers of
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redundancy.
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The authors reported no relevant financial disclosures.

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Introduction The Joint Commission defines “wrong-site surgery”

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Wrong-side nerve blocks (WSNBs) continue to be as an invasive procedure performed on the wrong part
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one of the most dreaded complications of locoregional of the body, wrong side or the wrong patient, thus
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anesthesia. An occurrence of a WSNB immediately exposing them to more than minimal risk. This defini-
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triggers root cause analysis, quality assurance and risk tion encompasses procedures performed both in and
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management committee meetings. The practitioners outside the OR.1 The WSNB is also considered a “never
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involved are always exposed to a great degree of scru-
tiny as the committees grind through the root cause
analysis in order to prevent future events. The occur-
rence of a WSNB may require reporting to the state
health department and/or lead to disciplinary action,
or even a license revocation in case of repeated error.
More importantly, WSNBs may lead to surgery on the
wrong side, bad outcomes and indefensible medico-
legal action.
event” by the Agency for Healthcare Research and
Quality.2 These never events are defined as unambig-
uous (identifiable and measurable), serious (resulting
in severe disability or death), and usually preventable
events.
In the first part of our review of WSNBs, published in
an earlier issue (Anesthesiology News Special Edition
2019;suppl:24-31), we summarized the literature con-
cerning this topic and discussed the incidence, general

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 02 1 27
principles and strategies related to decreasing the
chance of WSNBs and/or wrong patient blocks. This
article focuses on practical and readily implementable
prevention strategies as well as innovative technolo-
gies to decrease the risk for WSNBs. We searched the
PubMed database for keywords related to WSNB pre-
vention strategies, and online forums for any experi-
ences and practitioner recommendations regarding this
subject.
Prevention Strategies
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surgical outcomes,4 their utility regarding WSNBs actu-
ally has not been established formally. Although logic
should lead one to believe that it would be beneficial,5
complex sociological and cultural challenges, such as
hierarchy and perceptions of professionalism, may inter-
fere with the effectiveness of checklists in daily practice.
Neglecting these factors may increase the complexity of
coordinating a team around a single task.6
Of note, checklists are often generic and may not
be specifically developed for locoregional anesthesia
procedures. Not surprisingly then, several more spe-

cific guidelines and strategies were suggested, such as

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Checklists those by ASRA in 2014.3 The new recommendations of

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Checklists are well-established, inexpensive and easily the New York School of Regional Anesthesia (NYSORA)
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implementable strategies that have shown potential for also incorporate a “one last checklist” at the point of
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reducing errors in the medical world. They are a compi- care and a removable visual reminder on the ultrasound
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lation of safety measures that must be completed before probe cover itself (https://nextlevelcme.com/).
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performing medical procedures, including regional anes- Adding specific checklists for locoregional anesthe-
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thesia. Organized societies of anesthesiologists have sia has led to a reduction in WSNBs.7 However, physi-
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provided recommendations to prevent procedures on cians report increasing “checklist fatigue,” due to the
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the wrong side. As an example, the American Soci- repetitiveness of the checklist process and administra-
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ety of Regional Anesthesia and Pain Medicine (ASRA) tion. This leads to the danger of providers forgetting to
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appointed a task force to publish recommendations execute the checklist or to skipping certain elements,
for a preprocedural checklist specific to regional anes- defeating the very underpinning of the checklist pro-
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thesia.3 Although the use of checklists before surgical cess.8 This sparks controversy about the number of
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procedures has been demonstrated to positively affect checklists being performed and the actual clinical rele-
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vance of the checklists.

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Some institutions implement goal-specific check-

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list variations to improve preanesthetic site verifica-

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tion. An example is the “restricted needle technique,”

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adopted by the Hospital for Special Surgery, in New

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York City. In this method, nurses only provide the nee-

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dle to a practitioner after the site verification has been

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confirmed and agreed upon.9 Several difficulties were

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encountered when implementing this method, how-

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ever. Nurses reported frustration from the addition of

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another responsibility. Additionally, this sentiment was

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loss of autonomy caused by the removal of the block

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needles from the anesthesia cart.

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Procedural Markings
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Marking the correct site at which the nerve block will

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be performed is an intervention for WSNB published in

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many articles.10 The method for applying this marking

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varies between institutions. Examples include drawing

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an arrow with a marker, using colored bracelets11 and

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using stickers.10,12 Currently, there are no data available

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B to indicate which method is preferable.

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Despite the common use of marking, there are

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drawbacks to this method. Foremost, an abundance of

Figure 1.
An example of the problems with skin markings. (A)
shows a patient prepared and draped for a femoral
block. However, the nerve block procedure drape
obscures the skin markings, which can be seen only after
the procedure when the drapes are lifted off (B), thereby
defeating the purpose of the marking.
Photos courtesy of the authors.
markings (separately made by anesthesiologists and
surgeons) can confuse the medical team.13 Addition-
ally, different methods of marking can be confusing for
caregivers, especially those working in multiple institu-
tions, as the marking techniques may vary among dif-
ferent hospitals.
Second, applied markings can become obscured
when the patient is positioned, prepared and draped

28 A N E ST H E S I O LO GY N E WS .CO M
for the procedure,10 as many procedural drapes are not
transparent (Figure 1). Inability of the anesthesia pro-
vider to visualize the skin markings during the proce-
dure can lead to a WSNB despite a correct marking
of the block site. Transparent procedure drapes, with
or without indicia reminding clinicians to perform one
last checklist at the point of care, may be more effec-
tive (Figure 2). Transparent procedure drapes also allow
continuous observation of the skin markings, as well as
assessment of the anatomic landmarks, responses to
nerve stimulation and so forth.
A
Optimizing Surroundings and the Team
Instituting a block room improves efficiency and the
service offered by anesthesia providers. The University
College Hospital, in London, reported an increase in
the number and types of nerve blocks performed, cou-
pled with a reduction in late start times, after establish-
ing a block room.19 Implementing a block nurse team is
another measure that increases the safety of the anes-
thetic procedures, leading to fewer WSNBs.
In 2011, Duke University Hospital’s perianesthesia unit
incorporated this strategy. Results indicated an increase

It is important to keep in mind that the applied mark- in patient safety, perioperative efficiency and produc-
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ings can cause an “invisible gorilla effect.” This occurs tivity.20 The key to this strategy is the standardization
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when someone is paying close attention to something of patient care, including the administration of check-
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(in this case, the mark on the patient) and thereby often lists at the point of care. However, one of the difficulties
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fails to register or verify other information, even when in implementing a standardized checklist at the point
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obvious. In nerve blocks, this can occur when the mark of care is that peripheral nerve blocks are often admin-
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is initially made on the wrong side and is not checked istered in different locations, such as the OR, block
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again before the start of the block. room, recovery room or patient rooms on the ward.
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This makes it challenging to have all designated teams

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‘Time Out’ and ‘Stop Before You Block’ at these points of care familiarize themselves with the
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The “Time Out” or “Stop Before You Block”14 (SBYB) checklist protocols.
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process consists of a pause when the practitioner

checks whether the side of the intervention is correct Emerging Technologies
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just before performing the block.15 This is often included Johnstone et al21 proposed an electronic solution
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as the last step in a checklist, just before the insertion of that could lessen the cognitive load for practitioners.
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the needle. The correct side is confirmed using the sur- It consists of a USB device that can be attached to
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gical mark as a reference, asking the patient if possible an ultrasound machine and the nerve stimulator port
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and checking the consent form.16 It is important to use of the needle. The device senses the contact of the
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this triple method and not solely rely on the patient's

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response since they might already have received seda-

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tion during this step of the process. The Royal Brisbane

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& Women’s Hospital Human Research Ethics Commit-

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tee found that using SBYB helped to avoid WSNBs,

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and may have decreased complications after the block,

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without impeding the workflow. However, in a very

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busy practice with high turnover, this intervention may

indeed slow down the workflow when the number of
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surgical procedures is high.17

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Simulation Procedures
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In 2017, Pandit et al18 proposed the “Mock-before-

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you-block” protocol. The anesthesia provider prepares

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the nerve block as usual, but adds an empty syringe

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(without needle) or needle sheath to the sterile tray.

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After determining the correct position by using ultra-

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sound, the provider uses this empty syringe to perform

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a mock block by touching the skin of the patient. Dur- Figure 2.

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ing this action, the patient is asked if the mock block

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Use of a transparent procedure drape (EZCOVER,

is performed on the correct side. Only after confirma- MedXpress.Pro) allows for monitoring of the skin
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tion by the patient can the anesthesia provider access
the syringe containing the local anesthetic solution and
perform the nerve block procedure.
For a WSNB to occur when using this method, two
successive errors have to be made. This strategy, how-
ever, presents conflicts such as the need of an assistant
for the anesthesia provider at the moment of puncture.
It also can negatively affect workflow if the practice has
a large volume of patients.
markings and motor responses to nerve stimulation
when used throughout the procedure. Advantages
include 1) the motor response to nerve stimulation can
be observed; 2) allows for equipment pocket for syringe,
needle and ultrasound probe and the reminder to
perform a checklist (“Time Out”); and 3) the transparent
drape prevents claustrophobia, allows patient monitoring,
and can provide an air barrier between the patient and
care provider (e.g., for a COVID-19–positive patient).

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 02 1 29
needle with the patient's skin and generates a vocal
reminder (“Check the side of the block”) that can only
be stopped by pressing a confirmation button on the
device. A potential drawback of this strategy is that it
can be distracting for the practitioner, and/or inconve-
nient given that ending the reminder requires additional
personnel. This is because a practitioner administering
the block is typically sterile and gloved up. Therefore,
the use of this system requires assistance from a nurse
or another assistant.
Physical barriers are built-in action checks that do
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reminds the care provider to perform the last check-
list just before the block performance. Without remov-
ing the “STOP” sticker, the operator would not be able
to use the ultrasound and obtain images. In this way,
the practitioner is physically stopped in action and
reminded to implement the one last checklist, confirm-
ing the patient’s identity, procedure and laterality, just
before the procedure begins (Figure 3).
Conclusion
Checklist implementation at the point of care var-

not rely on the cognitive capacity of the staff. Recently, ies substantially among institutions. Consequently, no
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NYSORA has helped develop an ultrasound probe cover generally accepted standards exist, and despite the
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that incorporates a removable indicium (sticker) that checklists, WSNBs still occur. A challenge with the role
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of checklists in the prevention of WSNBs, in particular,

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is that they are notoriously difficult to implement and

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enforce at the point of care. During a peripheral nerve

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block procedure, it is possible that after the checklist

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and time-out process has taken place, the anesthesia

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provider could be distracted or interrupted to assist

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in patient care at another location. Upon return to the

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tasks of the nerve block performance, the provider may

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not have full recollection of laterality, which appears to

be a common scenario in the reports on WSNB events.
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These examples and other descriptions of mishaps

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and near-mishaps underscore the importance of imple-

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menting protocols with additional layers of redundancy.

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We particularly emphasize the importance of Pandit’s

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recommendation: “Mock before you block”—a built-in

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action check to prevent wrong-side anesthetic nerve

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blocks—which suggests that some type of reminder

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Figure 3. has to be built-in to the action itself in order to be

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effective.18
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A probe cover with indicium (sticker). The design requires

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The solutions depicted in Figures 1 and 2 are low-cost

removal of the sticker (EZCOVER STOP, MedXpress.Pro)
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physical barriers that mandate a stop and removal of

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before the ultrasound can be used. This stops the operator

the barriers before proceeding with the block, remind-
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in action and reminds the health care providers to perform

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the one last checklist at the point of care. ing the operator to perform the checklist at the point
of care.
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30 A N E ST H E S I O LO GY N E WS .CO M
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