Wrong-site regional anesthetic procedures are considered never events. The purpose of this review is to describe the phenomenon of wrong-site regional anesthetic blocks and identify preventive strategies.
The incidence of wrong-site block may be as frequent as 7.5 per 10,000 procedures. Factors contributing to wrong-site block include physician distraction, patient position change, scheduling changes, inadequate documentation, poor communication, lack of surgical consent, site marking not visible, inadequate supervision, reduced situational awareness, fatigue, cognitive overload, perceived time pressure, delay from World Health sign-in to block performance and omission of block time-out or block time-out occurring before final patient positioning. The American Society of Regional Anesthesia and Pain Medicine have created a 9-point checklist for regional anesthesia procedures.
Preoperative site verification and surgical site marking are mandatory. A time-out should occur immediately before any invasive procedure. Confirming the correct patient and block site with a time-out should occur immediately before all regional anesthetic procedures. If more than one block is performed on one patient, it is recommended that time-out be repeated each time the patient position is changed or separated in time or performed by a different team. The anesthetic team should uniformly implement robust guidelines and checklists to reduce the occurrence of wrong-site regional anesthetic procedures.
aDepartment of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital, Melbourne
bFaculty of Medicine, Melbourne Medical School, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria
cDepartment of Anaesthesia, Gold Coast University Hospital, Southport, Queensland, Australia
dDepartment of Anesthesiology and Pain Management, Dartmouth-Hitchcock Medical Center, Lebanon
eGeisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
Correspondence to Michael J. Barrington, Department of Anaesthesia and Acute Pain Medicine, St. Vincent's Hospital, Melbourne, 41 Victoria Parade, PO Box 2900, Fitzroy, VIC 3065, Australia. Tel: +61 3 9288 2211; e-mail: firstname.lastname@example.org