![]() In 2003, following several WSBs at our hospital, we instituted a formal pre-anesthetic time-out process that takes place before all PNBs. The Joint Commission mandated formal time-out procedures in 2004. WSBs may be preventable the success of a formal time-out process has been well-documented in reducing the risk of wrong-site surgeries. ![]() Not only do WSBs result in patient dissatisfaction, but they also carry the same risks of intended PNBs, including infection, persistent pain and paresthesia, and local anesthetic systemic toxicity. Over the past decade, however, multiple reports of WSBs and a focus on patient safety initiatives have brought this issue into the spotlight. In one study surveying academic regional anesthesiologists, WSBs were not considered a complication of PNBs. Although they are a significant complication, for many years they have been overlooked. WSBs continue to occur at an unacceptable frequency. It is unclear whether a formal pre-anesthetic time-out process was in effect in any of these reports. As determined by 3 registries, the incidence of WSBs in worldwide, national and multihospital health care system cohorts were 3.63/10,000, 1.6/10,000, and 1.28/10,000, respectively. Similar to wrong-sided surgery, this complication (deemed a “never-event” by various regulatory agencies ) continues to occur with alarming frequency. Wrong-site peripheral nerve block (WSB) is one troubling, yet avoidable, complication. While relatively safe, PNBs are not without complications. Its role in limiting opioid use, as well as the advent of ultrasound guidance improving success rates, may explain this increase. ![]() The use of the peripheral nerve block (PNB) as an important component of anesthetic and analgesic pathways continues to increase. A causal effect of the enhanced time-out cannot be determined given the risk of bias associated with before-after study designs and our lack of adjustment for potential confounders. Conclusion: We observed an association between the implementation of a dynamic, team-focused time-out process and a reduction in the incidence of WSBs at our institution. Results: The incidence of WSBs decreased from 1.10/10,000 before changes to the policy were initiated to 0.24/10,000 afterward. ![]() The incidence of WSB was compared pre- and post-implementation of the enhanced time-out policy for upper extremity, lower extremity, and all blocks by calculating relative risks with 95% score confidence intervals and performing Fisher’s exact tests. All WSBs from this period were reported to the QA/PI division and root cause analyses performed. Methods: We retrospectively analyzed data, from January 2003 to December 2016, taken from the quality assurance and performance improvement (QA/PI) division of the anesthesiology department at our institution, which maintained daily statistics on anesthetic types using quality audits from paper or electronic anesthesia records. We hypothesized that the enhanced process would decrease the incidence of WSBs. Purpose: We sought to compare the incidence of WSBs before and after this time-out process was implemented in 2003 and the enhanced form of it was implemented in 2007. Our institution mandated a time-out process before PNB in 2003, and then in 2007 made two more changes to our policy to mitigate risk: (1) the circulating/block nurse was the only person permitted to access the block needles after a time-out period was complete, the nurse gave the needles to the anesthesiologist and (2) the nurse remained at the patient’s bedside until the PNB was initiated. One potentially preventable risk is wrong-site blocks (WSBs). Background: Peripheral nerve block (PNB) has been shown to be safe and effective, and its use has continued to increase, but it is not without risks.
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