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Stop Wrong-site nerve blocks
Wrong-site nerve blocks (WSNB) are considered as “never events” in health care, yet they continue to occur and pose a risk of serious consequences.1 WSNB can harm the patient, increase treatment costs and lead to a loss of trust in the health care system. Medico-legal claims arising from WSNB are indefensible, and typically settle as a malpractice damage.2
A nationwide patient safety campaign in the UK called “Stop Before You Block” (SB4YB) has aimed at reducing the risk of wrong-site and wrong patient nerve blocks during regional anesthesia.3 Although this highly valuable campaign has been widely promoted, wrong-site blocks have not been eliminated, and in fact are increasing – from 34 in 2018/19 to 53 in 2019/20, a rise of 36%!4
Checklists and procedural markings are commonly used measures to prevent the occurrence of WSNB. However, checklists are notoriously difficult to implement and to enforce at the point of care. Commonly used markings on the patient can be confusing, may become obscured during the procedure or may be ineffective due to checklist fatigue. Moreover, the “Invisible Gorilla” study has shown that practitioners often fail to notice obvious things in their field of vision when they are intensely focused on another task, such as administering a nerve block.5
The Safe Anaesthesia Liaison Group (SALG) recently published an update to its SB4YB initiative to help implement a universal standard operating procedure (SOP) in this area. The new SOP: ‘Prep, Stop, Block’ includes three steps6:
Prep: Preparation of drugs, equipment, sterility, preliminary scanning, positioning of patient.
Stop: A time-out immediately before the insertion of the needle when the anesthesia providers check the block site and verbally agree that it is correct.
Block: After the confirmation of the block site, the procedure is performed.
EZCOVER® ultrasound probe covers are available with a stop before you block safety shield, providing a physical barrier to instigate a stop moment immediately prior to the start of the procedure. The user must remove the stop shield from the probe cover just before the ultrasound can be applied to perform the nerve block procedure. With this action-based reminder built in EZCOVER®, it is an effective solution to introduce another layer of safety in preventing WSNBs in accordance with the latest SOP.
• Assures compliance with the WHO checklist (JCI standards IPSG4 and IPSG.4.1)
• Complies with the new prep-stop-block SOP
• Designed to reduce risks of wrong-site blocks
[1] Agency for Healthcare Research and Quality. Never Events. September 7, 2019. Accessed July 12, 2021. https://psnet.ahrq.gov/primer/never-events
[2] Deutsch ES, Yonash RA, Martin DE, et al. Wrong-site nerve blocks: A systematic literature review to guide principles for prevention. J Clin Anesth. 2018;46:101-111.
[3] Regional Anesthesia UK (RAUK), Safe Anesthesia Liaison Group (SALG). Stop Before You Block. 2015. Accessed July 12, 2021. https://www.ra-uk.org/ index.php/ stop-before-you-block
[4] NHS England, Never Events Data Base 2018-2021; https://www.england.nhs.uk/patient-safety/never-events-data/
[5] Vandebergh V, Coll V, Keunen B. Prevention of Wrong-Side Nerve Blocks: Part 2. Anesthesiology News. 2021 Sep; 27-31
[6] N. Haslam, N. Bedforth, J. J. Pandit. ‘Prep, stop, block’: refreshing ‘stop before you block’ with new national guidance, 2022 Apr, Anesthesia, Volume77, Issue4, 372-375
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