The Anaesthetic Period: Prevention of Wrong-Side Surgery
Factors that contribute to wrong-side procedures Prevention of incorrect side block performance General Wrong-side procedures are classified as ‘ never events ’. However, they still occur at an unacceptable rate. As integral members of the surgical team and advocates for patient safety, anaesthesia providers are critical to processes that aim to prevent these. Of note, it is estimated that wrong-
Factors that contribute to wrong-side procedures
Prevention of incorrect side block performance
Wrong-side procedures are classified as ‘never events’. However, they still occur at an unacceptable rate. As integral members of the surgical team and advocates for patient safety, anaesthesia providers are critical to processes that aim to prevent these.
Of note, it is estimated that wrong-side blocks are performed with an incidence 10 times those of wrong-side procedures. The factors below contribute to this.
Factors that contribute to wrong-side procedures
Physician factors:
- High-pressure environment
- Fatigue
- Lack of clear hierarchy/responsibility
- Staff change during the procedure
- Failure to check or mark site
Patient factors
- Sedated/confused or block sited after induction
- Similar patient names
- Language/communication barriers
- Abnormal anatomy
- Multiple blocks in the same patient
- Haemodynamic instability leading to distraction
Procedural factors
- Change in patient position
- Change in order of theatre list
- Wrong site marked
- Marking erased
- Distractions – verbal, phone call, teaching, etc.
While the WHO checklist (Appendix I) offers some protection from wrong-side procedures, it is recommended that further safeguards are put into place. The attending anaesthetist should take the following steps to prevent incorrect side procedures:
- Verbally confirm the site and side of the surgery with the patient during the preanaesthesia consultation and document the discussion and confirmation of site/side against the booked procedure.
- Ensure that the correct side is marked clearly. While this is primarily the responsibility of the consenting surgeon, as patient advocates, it falls to anaesthesia providers to confirm that this has been done. Options include:
- Indelible marker – consider marking the actual needle insertion site – be aware that this may lead to confusion with previously placed surgical side markers, so ensure this is clearly marked as a block site.
- Brightly coloured armband (of a colour different to those typically used by nursing staff)—visible at all times before skin incision—not necessarily on the limb to be operated on but lateralised to the correct side and visible.
Prevention of incorrect side block performance
Previously, the ‘STOP before you block’ model was developed to reduce the risk of wrong site/side blocks. However, the number of incidents was not significantly decreased. The model has been adjusted in the interim and has been produced as a ‘Prep, Stop, Block’ model.
The model is presented as a standard operating procedure (SOP) and has the following steps:
Prep
- The performing anaesthetist prepares the local anaesthetic solution in a clearly marked syringe with a suitable block needle. This is then handed off to the assistant, out of reach of the person doing the block.
- The anaesthetist then cleans and drapes, making sure to leave the previously placed mark visible.
Stop
- The stop moment happens after preparation is completed. When ready, the anaesthetist announces that all preparation is completed, and they are ready to block.
- At this stage, the anaesthetist and the assistant view the surgical site mark and verbally confirm the correct side, and the assistant reconciles this with the consent form.
Block
- Only after the correct side is confirmed does the assistant hand the prepared tray to the anaesthetist, who immediately performs the block.
- Any delay or interruption requires beginning the process from step 1.
The most important aspect of this updated model is that it is performed immediately before needle placement. The Prep, Stop, Block approach was devised by Regional Anaesthesia United Kingdom (RA-UK). It is currently endorsed by the Royal College of Anaesthetists (RCOA), Safer Anaesthesia from Education (SAFE), Royal College of Surgeons and the Association of Anaesthetists of Great Britain and Ireland (AAGBI).
General
It is critical to appreciate the role of distraction in the performance of checklist-based procedures like the WHO and anaesthesia safety checklists – should these be interrupted for any reason, the checklist should be started from the top. Extreme care should be taken if the patient is to be positioned in positions other than supine after induction. Ultimately the creation and curation of strong team dynamics in the operating theatre will go a long way toward decreasing the risk of wrong-side procedures in the context of the provision of medical and surgical care.
South African Society of Anaesthesiologists (SASA) Practice Guidelines_2022_Reviewed by: M Blackburn