Abstract ID: A31
Abstract Title: A process to eliminate wrong site regional anesthetic blocks: A case report
Poster Type: Poster
ABSTRACT BODY
Introduction: Surgical site verification (SSV) is among the leading issues concerning patient safety today 1. Regional anesthesia (RA) has recently enjoyed a tremendous resurgence over the past few decades. Specifically, peripheral nerve blockade (PNB) has evolved into a major component of many anesthetic practices. These blocks have also supplemented and improved many post-operative analgesic regimens. At HSS, we perform over 18,000 anesthetics per year with 44% consisting of PNB. Although wrong site RA may not have the same level of severity as wrong site surgery, there is certainly the potential for serious medical and legal liability. The objective of this case report is to describe a process we have developed to eliminate wrong site RA blockade.
Case Report: A 68 yo female, suffering from an infected left hip prosthesis was scheduled for removal of the implant. The anesthetic plan consisted of a combined spinal-epidural (CSE) anesthetic with a psoas block for post-operative analgesia. The patientˇ¦s preoperative evaluation was completed in the holding area, and surgical and anesthetic consents were obtained. The surgical site was confirmed per hospital protocol which included verbal patient confirmation and the surgeonˇ¦s initials on the operative site. A last-minute scheduling change occurred as another OR became available. This new room had been set up for a right THR. The patient was brought to the OR and monitors were applied. The patient was incorrectly placed in the left lateral decubitus position and a right psoas block was performed using 30 ml of 0.25% bupivacaine with epi, followed by a CSE. Following administration of the blocks the surgical team began final positioning and discovered the patient was on the incorrect side and the psoas block had been performed on the incorrect side. The patient was positioned correctly, and the surgical procedure proceeded uneventfully. At the completion of the surgical procedure, a left sided psoas block was administered.
Discussion: In response to this case, we have developed a "Pre-Anesthetic Site Verification" program as a supplement to our pre-op SSV policy. The program incorporates the JCAHO recommendations for SSV 1 and applies them to ensure correct regional block placement.
The features are as follows:
- A written pre-op site verification is performed by the anesthesiologist independent of the surgical site verification.
- The anesthesiologist, circulating nurse and patient must visually confirm the surgical site and laterality as documented on the consent form prior to block placement.
- We have decided against marking the block placement site in order not to be confused with the site marking performed by the surgeons.
- We have begun a rigorous educational campaign to enforce and encourage 100% compliance.
Wrong site RA are highly preventable, and potentially serious anesthetic errors. Policies, such as the one described above, should be considered at any institution performing PNB. We fully expect that the anesthesiologistˇ¦s pre-anesthetic diligence to site verification will have a positive and dynamic effect in preventing both wrong site RA and surgery.
References:
1. Wrong Site Surgery Summit. Joint Commission Perspective. 2003 Aug;23 (8):8-9.
ATTACHED FILES
Reg Anesth Pain Med 2004; 29(2):A31