Audit on stop before block Regional anaesthesia safety check

1. AUDIT-STOP BEFORE YOU BLOCK
Dr. Harish Ningegowda
Dr. Mamatha Kumar
Department of Anaesthetics – West Hertfordshire NHS Trust
14-06-2016

2. WHY THIS AUDIT ?
• In SACH Elective Orthopaedic list – March 2015
• 76 yrs old female posted for Right TKR
• PMH : Hypertension on Amlodipine. Previous GAs for Left
TKR in 2011, Hysterectomy in 1998
• Anaesthetic plan : Enhanced recovery Spinal/ GA + Local
infiltration by Surgeon + post op opiods discussed.
• Patient refusing for Spinal : Because in 2011 for Left TKR –
Difficult Spinal, was given GA.
• Refusing for Local anaesthetics infiltration as she was
feeling numbness/ weakness in her legs for few weeks after
GA + Nerve Block.
• Agrees for GA only.

3. SACH Theatre 3
Uneventful induction
Surgery commenced
Review of her notes and discussion with the
patient what happened in 2011.

4. • In October 2011 : Elective Left TKR
• ASA 2
• Planned under Spinal + Sedation
• Spinal Anaesthetic - Multiple attempts -Difficult Spinal
Planned for GA and Femoral Nerve block
• Uneventful GA. Right Femoral Nerve block performed
USG guided with 20mls of 0.5% Chirocaine.
• Documented as Right Femoral Nerve block
• Surgery was done on the correct side[Left].
• WHO Sign out : Nothing documented
• Post op patient was prescribed PCA Morphine

5. • No documentation of explanation to patient about wrong
site block
• No documentation of Incident form filled.
• No post operative Anaesthetic follow up.
• Patient was feeling numbness/ weakness of Right lower
limb for which nobody was able to give proper explanation.
• She was adviced to have the other side Knee replacement
as well. She discussed with Orthopaedic Surgeon what
problem she had in 2011 . Surgeon was also not able to give
a convincing answer.
• In preoperative clinic was told that she might had
? reaction to local anaesthetics.

6. WHAT HAS HAPPENED

7. WHAT HAS HAPPENED
WRONG SIDE BLOCK

8. STOP before
you block
Notice for anaesthetists
and anaesthetic assistants
• A STOP moment must take
place immediately before
inserting the block needle
• The anaesthetist and
anaesthetic assistant must
double-check:
- the surgical site marking
- the site and side of the block

9. Safe Anaesthesia Liaison Group (SALG) in November 2010 started
STOP BEFORE YOU BLOCK campaign
The Stop Before You Block Process
1. The WHO sign in is performed as usual. The patient identity, consent form
and marking of the correct surgical site are confirmed.
2. IMMEDIATELY before needle insertion in the nerve block process the
correct site is confirmed again. This involves:
• Visualising the surgical arrow indicating site of surgery
• Asking the patient to confirm the side of surgery (if conscious)
• Double checking the consent form for operative side (if patient
unconscious)
• The Stop Before You Block moment can be instigated by any member of
the anaesthetic team (anaesthetist, anaesthetic nurse, operating
department practitioner or anaesthetic physician assistant).

11. When and Where Audit done
In SACH Theatres – Elective cases
From May 2015 to July 2015

12. RESULTS
58 cases involving Unilateral Blocks.
Types of Blocks : ISB/Axillary 30
Ankle/Popliteal 19
Truncal Blocks 9
Grade of Performer : Consultant 38
SAS 15
Trainees 5

13. RESULTS
Block performed under
GA Sedation Awake
30 28 0

14. STOP Before Block performed
YES NO
32 26

15. YES in 32 out of 58 patients
Visualising the arrow indicating surgical site
YES NO
28 4

16. Asking the patient to confirm the site of
the surgery
YES NO
18 40

17. Checking the Consent form for the correct
operative site
YES NO
16 42

18. Person who initiated the STOP before Block
[32 out of 58]
ANAESTHETIST 31
ODP 1

19. BLOCK was performed in
AR 58
THEATRES 0
RECOVERY 0

20. Discussion
• ONLY 32 out of 58 cases had STOP before block
performed.
• Out of these 32 cases the steps of STOP Before block
were not followed as recommened.
• Less initiation or involvement of ODPs.
• Wrong site block is classified as Never event.
• Only in 16 out of 58 cases consent form was checked.

21. Causes for Wrong sided Block
• Distraction in the Anaesthetic room.
• Time pressure.
• Ambiguous terminology (“right”)
• Language difficulties (patient or operator).
• Teaching, change in routine or technique or personnel.
• System factors Time delay between WHO surgical safety
checklist and performance of block.
• Change in position.
• Social activities in the Anaesthetic room.
• Covering-up of the surgical mark with blankets in an
attempt to keep the patient warm.
• Human errors.

22. Complications of Wrong sided Block
• Complications from the unnecessary block eg. nerve
injury, pneumothorax.
• Prolonged recovery & delay in mobilisation.
• Potential to proceed to wrong-side surgery.
• Complications from performing a second block eg LA
toxicity.
• Inability to provide optimal analgesia.
• Potential for cancellation of surgical procedure &
Financial loss to Trusts.
• Trespass – procedure on unconsented body part.
• Delayed hospital discharge.

23. Recommendation/Conclusion
• STOP Before Block posters in the Anaesthetic rooms.
• STOP Before Block stickers on Ultrasound machines and
Nerve stimulators.
• Verbal confirmation with patient on arrival to Anaesthetic
room.
• Specific marking for Anaesthetic related procedures by
stickers.
• WHO Sign in : Anaesthetist to do with surgical site exposed.
• Educate/Workshops for ODPs/ ODP Trainees.
• Feedback from Anaesthetists who were involved in
wrong-sided nerve blocks or near-misses in the past.
• Re audit.