Abstract ID: A17
Abstract Title: Patient participation does not prevent wrong side procedures
Poster Type: Either
ABSTRACT BODY
Introduction:
The topic of wrong side surgery or procedures is one of the major issues of the National Patient Safety Goals posted by the JCAHO. It has led to a number of regulations in hospitals throughout the country to initiate protocols for the identification of the surgical or procedure site with a “Time out” immediately before incision.
Case Report:
Case 1: A 16-year-old patient for left ankle surgery was taken to our block area in order to perform a femoral and popliteal block for post-surgical analgesia. His left leg was marked correctly as the site of surgery with an “X”. He was unsedated and fully oriented. His mother who is an OR nurse at our hospital was present the whole time. The popliteal block was placed on the correct (left) side in the prone position. After supine positioning for the femoral block, the patient lifted his boxer shorts to allow puncture of the groin and pointed towards the right side after being asked to verify the surgical site. The right femoral nerve was accidentally blocked. The error was discovered during positioning in the operating room and the left femoral nerve was then successfully blocked. Surgery could proceed with good block quality and the patient was discharged home with no further sequelae. Both, patient and mother took the wrong side block with humor and were satisfied with the good post-operative pain relief of the successful block.
Case 2: A 17-year-old male was taken to block room in order to perform a single shot popliteal block for postoperative pain relief from right ankle surgery. After positioning him prone the patient was asked again to lift the leg we were operating on to verify the site. He lifted the leg and a left popliteal block was performed. The patient or the staff did not note the error until he complained of pain in the recovery room, although another verification and second “Time out” maneuver occurred in the OR. The correct site was later blocked successfully in the PACU and the patient had an uneventful recovery and was satisfied with his pain relief.
Discussion:
These two case reports highlight that position change during multiple peripheral nerve blocks can lead to right and left confusion even in a coherent, oriented, and unsedated patient (and the practitioner). Both patients had already undergone two verifications of the surgical site by nurses, one by the surgeon and one by the anesthesiologist aided by forms, which were signed at the time the sentinel error occurred.
Hospital policy requires that the surgeon marks the extremity to be operated on personally with his initials, checking the consent, the H&P in the medical record and utilizing patient’s cooperation whenever possible. I now also mark all block sites, especially in those procedures where two peripheral nerve blocks need to be performed before going to the block room as an additional safeguard. The cases raise the question whether multiple verifications really increase safety or might sometimes add even more to the confusion.
One clearly responsible staff member who performs the patient identification, verification and marks the surgical and block sites with one person to double check might be the most efficient and safe way to ensure correct site surgery and regional anesthesia.
ATTACHED FILES
Reg Anesth Pain Med 2004; 29(2):A17