How To Prevent Wrong-Site Nerve Blocks

The Joint Commission defines Wrong-Site Surgery (WSS) as an invasive procedure performed on the wrong part of the body, wrong side, or the wrong patient, thus exposing them to greater risk.

A WSNB immediately triggers root-cause analysis, quality assurance, and risk management committee meetings. It may require reporting to the state department of health and/or lead to disciplinary action, or even a license revocation in the case of repetitive error. More importantly, WSNB may lead to surgery on the wrong side, undesirable outcomes, and indefensible medico-legal consequences.

In spite of all this, wrong-site nerve blocks (WSNB) continue to be one of the most dreaded complications of nerve blocks.

A few years ago in my practice in New York, I was involved in a “block on the wrong side” incident. I remember that day like it was yesterday. I was called to the operating room to assist the trainee with an interscalene block.

I thought about this for days and I kept rewinding the film, trying to work out what we could do to prevent this from happening. What could we do to grab attention, to flag up a strong signal as a reminder to perform the one final, last time-out and checklist BEFORE the needle goes in?

Now, while we know the value of checklists to reduce errors in the medical world, their effectiveness depends on the conscious attention of the practitioners. With so many checklists to be completed on the patient’s journey to the operating theater, the risk is that they become routine. The ‘checklist fatigue’ can lead to situations where providers forget to execute the checklist at the place where it matters most: point of care, immediately prior to the nerve block administration.

But no generally-accepted standards exist, and, despite the checklists, WSNB still occurs. So, how do we make sure that the critical “one last checklist” is given the full attention it deserves?

The answer may lie in some sort of a physical barrier that prevents the use of the ultrasound machine until the point of care checklist is done. And here’s the answer we came up with: NYSORA collaborated with the industry to develop the first probe covers specifically developed for ultrasound-guided nerve blocks.

In our practice of nerve blocks at NYSORA, we have adopted ultrasound probe covers that feature an easy-to-remove sticker that bears the message “STOP before you BLOCK”.  The sticker presents an actual physical barrier that must be removed before the ultrasound can be used to acquire images.

This is a strong visual reminder to do that crucial  “ONE LAST checklist” – a time-out to be sure that we have the correct patient, procedure, and laterality before the needle goes into the patient.