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Wrong-site regional anesthesia: review and recommendations for prevention?

Barrington, Michael J.a,b; Uda, Yoshiakia,b; Pattullo, Simon J.c; Sites, Brian D.d,e

Current Opinion in Anaesthesiology: December 2015 - Volume 28 - Issue 6 - p 670–684
doi: 10.1097/ACO.0000000000000258

Purpose of review 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.

Recent findings 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.

Summary 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:

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