Two cases of a wrong-site peripheral nerve block and a process to prevent this complication. uri icon

Overview

abstract

  • OBJECTIVE: The purpose of this study was to develop a system to prevent laterality errors while performing peripheral nerve blockade. CASE REPORT: The report depicts 2 cases of peripheral nerve blocks being performed on the wrong (nonoperative) extremity. An analysis of the circumstances in each case reveals distractions, schedule changes, and communication breakdown, which contributed to the error. A protocol to prevent these errors from occurring in the future, based on the Joint Commission on Accreditation of Healthcare Organizations guidelines, to eliminate "wrong-site" surgical procedures is developed and discussed. CONCLUSIONS: The anesthesiologist plays an important role in preventing wrong-site peripheral nerve blockade and surgery. The protocol developed for "Pre-Anesthetic Site Verification" as a supplement to our preoperative site verification policy is invaluable in preventing wrong-site anesthesia and surgery.

publication date

  • January 1, 2005

Research

keywords

  • Medical Errors
  • Nerve Block
  • Peripheral Nerves

Identity

Scopus Document Identifier

  • 13244292483

Digital Object Identifier (DOI)

  • 10.1016/j.rapm.2004.08.021

PubMed ID

  • 15690274

Additional Document Info

volume

  • 30

issue

  • 1