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Correcting Wrong Site Anesthesia Errors

Terresa L. Roulhac
National University


There are number of issues facing healthcare in the United States that are not exclusive to
one area and often occur during routine tasks. Although many of these issues are
addressed on a daily basis, the need to fix them is still important. Medical errors are a
continuous problem seen nationwide in hospitals and surgical centers. More exclusively
wrong site peripheral nerve blocks have been seen in hospitals and ambulatory surgical
centers across the United States (Hudson, & Sullivan, 2012). The first section of the
paper takes a look at a number of reasons why peripheral nerve block errors occur and the
risk factors associated with them. Also, examines a number of failed solutions that have
been utilized in the past. The second section of the paper examines solutions to decrease
the number of peripheral nerve block errors and ways to change the culture to prevent
them in the future.
Keywords: teamwork, time-outs, changing culture


Correcting Wrong Site Anesthesia Errors

Medical errors account for over 400 thousand deaths in America each year
(McDonald, 2013). Surgical patients often fall victim to medical errors before an incision
is even made. Although surgical patients become victim of a wrong site nerve block error
they are, however, in no real danger of losing a life or limb. Boodman states that a few
causes of wrong-site mistakes are, mixing up the left and rights sides; operating on
patients whose documentation belongs to another patient or marking the wrong vertebrae
in a spinal surgery(2011). More specifically when there is more than one site to be
anesthetized on the same patient the risk for an error increases. For example, when a
patient is scheduled for an ACL (Anterior Cruciate Ligament Repair) reconstruction the
normal practice in many hospital and ambulatory surgery centers is to perform a popliteal
sciatic nerve block and femoral nerve block prior to surgery. (Jansen, Miller, Arretche, &
Pellegrini, 2009) The popliteal nerve block is done in the prone (patient laying on his or
stomach) in the face down position, and the femoral nerve block is done in the supine
(patient laying on his or her back) in face up position. See Figure 1 for a detailed example
of the difference between popliteal and femoral nerve block approaches.
There are a number of reasons why Medical errors occur and causes that can be
addressed. Wrong site anesthesia nerve blocks are preventable medical errors and the
occurrences of these errors are a concern for medical staff each day.
Because to Err is human, operating room staff members should have fail-safe
provisions in place in an attempt to prevent wrong site nerve block errors from


There are a number of potential causes of popliteal and femoral nerve block errors
that can be broken down into process factors and system factors. System factors focus on
the lack of checklists, and the exclusion of certain surgical teams members. Whereas,
process factors focus on things like, inadequate communication with team members or
one patient having multiple procedures done. (Mulloy & Hughes, 2008) Table 1. Gives a
more detail breakdown between system factors and process factors that contribute to
medical errors.
Benchmarking can be a successful tool to determine root causes and potential
solutions to a problem. Benchmarking allows for an organization to compare themselves
to others in the same field and gauge what works and hasnt work for others. (Suttle, n.d.)
One tool that can be used to benchmark is to interview other professionals in the same
field. Obtaining views from professionals in the same field often gives a great insight to
issues and problems within healthcare. Doctor Mark Rasmussen, A member of the
Anesthesia Service Medical Group (ASMG) was asked what he felt were contributions to
nerve block errors, what changes to the culture will help to prevent them, what changes
would he like to see in the future, what works well in his facility. According to Dr.
Rasmussen in regards to contributing factors associated with nerve block errors,
What contributes to the error is a pretty broad question. Its infrequent enough that
each case almost needs to be considered individually. I would have never predicted
that a stressed lightly sedated patient would present the wrong limb to me to be
blocked. Patients are often so intimidated by doctors and nurses they wont stop them
from taking care of the wrong limb. (M. Rasmussen, personal communication from
26 August 2014)


Changing the culture is often a topic in healthcare that plays as huge of a part of
medical errors, like contributing factors. Regarding the culture Dr. Rasmussen stated,
Unfortunately, I think the title Dr. gives a substantial placebo affect to
patients. I need someone to trust me immediately with their life sometimes and its
much harder to do what I need to do without their assumption that I am well
trained and have their best interest at heart, which I do. I have a Canadian
partner (Breen) who doesnt make that connection and he has everyone call him
by his first name. He might be right but I dont know how to make that transition
without making some people feel a little weird. Some nurses and most patients in
As far as wrong site regional anesthesia, I think this might help just a little. But I
think the cultural tide (which you cant change) will eventually wash over titles.
We dont use Mr., Ms. Mrs. as frequently as we did 20 years ago. Were all moving
to a more familiar way of addressing each other. Just watch Downton Abbey.
(M. Rasmussen, personal communication from 26 August 2014)
Understanding the stress that is often felt in the operating room can enlighten how
wrong site nerve blocks occur. For example, if the surgeon rushes the surgical team to get
the patient into operating room to start the case early its understandable to think that a
medical error can occur because the staff might overlook the second nerve block site in
an attempt to satisfy the surgeons wishes. Communication is important and will not flow
as well among team members if one feels stressed because of time constraints or if he or
she is feeling rushed.


Real world situations help to determine when a problem exists and how an
organization can learn and grow from it. One example of a real world situation occurred
at a local surgical center in San Diego, California. A patient was brought to the operating
room for a popliteal and femoral nerve block prior to a routine Left knee arthroscopy and
ACL reconstruction surgery. The patient received a femoral nerve block on the left lower
extremity, and was flipped to the prone position to receive a popliteal nerve block on the
same extremity. Unfortunately, the patient received the popliteal nerve block on the right
lower extremity. Once the error was identified, the surgeon was informed and the patient
still underwent the scheduled surgery, but had to stay in the facility longer than scheduled
to make sure he regained feeling to the extremity prior to discharge. This meant,
additional staff had to stay in house which cost the organization money and
inconvenienced the patient. The patient and family had concerns of whether or not the
patient would regain feeling back to the non-operative leg. The staff members involved
felt horrible about the error. Management was informed and began the process to
determine which factors contributed to the error. The entire team was affected by the
To Err is human is one of the major reasons medical errors occur.
Anesthesiologists have the unique job of helping patients to achieve a virtually painless
surgery pre-operatively, intra-operatively, and post-operatively. Providing nerve blocks to
patients can help them but can also harm if not done at the right dose, or site of the
surgical procedure.
Unlike with a surgical medical error the likelihood of death is reduced, however
patients can have very serious consequence or adverse reactions from wrong site nerve


block errors. Longer surgical stays in ambulatory surgery centers and loss of complete
feeling to the extremity are a couple of negative affects from wrong site nerve blocks.
Also, moral is lowered and a feeling of failure often accompanies operating room staff
members that are apart of wrong site nerve block errors.
Understanding the issue is one part in problem solving, and looking at ways to
incorporate the change is another part. One way to reduce the amount of wrong site nerve
block errors is to change the culture through new practices. By changing the culture, an
organization is taking steps to improve the process, open up communication and improve
patient safety. The healthcare system as a whole is made up of hierarchy and power, and
often staff members do feel that he or she cannot make a difference. (Greif, 2010) Many
staff members also fear of losing their job if an error occurs. Teamwork is essential in the
operating room. Andrew Carnegie explains, Teamwork is the ability to work together
toward a common vision. The ability to direct individual accomplishments toward
organizational objects. It is the fuel that allows common people to attain uncommon
results. (Kerpen, 2014)
Punishment is not a way to correct the problem of wrong site errors. Dr.
Rasmussen made the point that,
The answer is not to be more vigilant or dont let it happen again or well fire
you, etc. I personally think the answer is changing the workflow so that it makes
it more difficult to do the wrong task and then bake it into the organization. Shift
that shame from the outcome to those who dont follow the proper procedure for
an anesthesia block. But anything that requires will power will absolutely fail at


some point. If you can create a mindless habit that prevents it from happening all
the better. (M. Rasmussen, personal communication from 26 August 2014)
Although staff might not feel that he or she can make a difference, once an
organization takes the first steps to attempt to change the viewpoint of hopelessness
among its staff then true change can take place.
Changing the culture is often hard to incorporate into organizations that have
practices in place that staff are used to, but with a little coaching and explanation of the
benefits it can be done in a few simple steps. The first step in changing the culture is to
look at the system that is already in place and determine what works and has not worked
in the past. By examining systems that are currently in place, staff can brainstorm and
look at causes as well as potential solutions to the problem. Brainstorming is a great way
for an organization to encourage creative thinking and to bring in new ideas. (London,
2014) The second step would be to establish protocols that are simple to understand and
concise to ensure that the right extremity has been established and properly marked.
Sticking to the established protocols is key to safety of the patient in wrong nerve block
site errors. (OReilly, 2010)
Protocols are important, but in order for protocols to be effective each member of
the team must feel important to the team. Involving all members of the team to include,
Anesthesiologist, Surgeon, Circulating nurse, Scrub technician and the patient is
important in reducing wrong site nerve block errors. Egos play a huge part in teams
breaking down in the operating room, especially if not all team members feel important
to that team. When Dr. Rasmussen was asked his opinion he stated,


.. Drop the egos and call each other by first names. I need someone to be able to
say, Mark, are you sure you want to do that? without hesitation. I think
surgeons would be least likely on board with the idea. But I hope in one to two
generations the OR becomes a team with a bunch of specialists who have each
others back rather than one person with all the focus. (M. Rasmussen, personal
communication from 26 August 2014)
Understanding that each member of the team is an intricate part allows for a
system that flows more easily. By coaching peers and modeling ideal behaviors the
potential occurrence of errors will be decreased since all members of the team will be
actively engaged in every aspect of the procedure (, 2013) Although the ideal
operating room setting would allow for a free flow of communication in which every part
feels as if they can communicate without feeling subpar, at present time, the operating
rooms hierarchy presents a problem. More often than not, the surgeon feels that he or she
has the first and last say in what happens in the operating room. Surgeons are
theoretically superior to their technical and nursing staff, but the responsibility of caring
for the patient is a joint task. Because the surgeon was considered the leader of the pack
in the past it is often hard for them to actually step back and allow other teams members
to take the lead in the care of the patient. (Miller, 2010) Surgeons often feel that they
have earned the right to act and be a certain way. Although, the surgeon may feel that he
or she should be in charge, once a surgeon sees the benefit of teamwork, the idea of him
or her being the only one to lead the team will change, thus changing the culture and
adding one more tool to potentially eliminate the chance of errors in the future.



Involving all members of the team will help to provide a safety net against wrong
site injections. Asking questions that will create an environment where every member has
a part in the process for improvement can be used to answer any system failures. Dr.
Rasmussen brought up a couple of great questions that the entire team could use to
improve the process.
How do you do a particular procedure? What constitutes the safe execution of a
given procedure, How can I make it so rote that even if I do it mindlessly when I
am distracted and tired that I have enough safeguards to prevent me from
screwing up. (M. Rasmussen, personal communication from 26 August 2014)
Once every member of the team is engaged, keeping communication lines open is
the next step, especially if the patient is going to be handed off to another member of the
team. A simple checklist can accompany the patient throughout his or her stay at the
facility to aid in giving the team a second tool to help reduce wrong site nerve block
errors. (Fields, 2011) Checklist are only as good as the person doing them, the last part
of this step would be to hold individuals accountable for the checklists to ensure that they
are being done correctly and in a timely manner.
Often times in routine surgeries there will be more than one site to be anesthetized
and the potential for error increases even with a great checklist in place. When more than
one surgical site is involved the circulating nurse can keep all medications separated until
time of use and multiple time-outs can be conducted to prevent the error from occurring.
By conducting a standardized Time-Out the facility will reduce the potential occurrence
of an error. The system will weaken if a surgeon is allowed to mold the Time-Outs to
benefit what he or she feels it should be, thus lowering patient safety. (, 2013)



The Time out process happens before any invasive or non-invasive procedure happens to
the patients. Performing multiple time outs will help reduce errors and improve patient
The normal standard of practice does not include the surgical team to perform
multiple Time-Outs. Adding additional time-outs will increase time spent with one
patient, and slow the workflow process, but the benefits of patient safety outweigh the
cost of spending an additional five to ten minutes to verify site location.
Multiple time-outs done in a sequential order do a number of things for the staff.
The first thing that it does is give a universal standard that can be copied and
remembered. This allows for new members to step in and perform the job without
disrupting the workflow. The second thing that it does is to allow for more than one
individual to be held accountable for making sure that the right site is being anesthetized.
That second person acts like a safety net, or a check and balance during the time-out
The first step in performing multiple time-outs is decide which order will work
best for your organization and O.R. team. For example, if the suggested universal method
is to perform the popliteal block first and then flip the patient over to perform the
femoral, establish those guidelines in writing.
The second step would be to perform a time-out prior to the first nerve block, turn
the patient over and then perform the second time-out prior to the second nerve block
being performed.



The last step in the multiple time-out process is to be consistent and to not deviate
from the established norm. Also, engage all members of the team in the anesthesia timeouts as well as the surgical time out process.
Medical errors are responsible for many deaths in America each year, and surgical
patients have often become victim due to wrong-site surgical procedures. When medical
errors occur major damage and injury can happen to a patient. The operating room staff
must be vigilant in their practices to avoid those errors from ever taking place. More
specifically when wrong site nerve block errors occur the operating room staff needs to
determine what the root causes were, what were all the contributing factors, create and
implement a plan for process improvement. One way that can be achieved is by
benchmarking. Benchmarking is an important tool to determine what is working or not
working. One way to benchmark is to speak with healthcare professional like Dr. Mark
Rasmussen and examine what changes of improvement have been made at his facility
and compare pros and cons. Many recommendations can be made to change the culture to
increase the flow of communication, reduce the healthcare status hierarchy, and increase
the frequency of time-outs prior to any procedure whether it is invasive or non-invasive.
The future of healthcare is constantly evolving and growing. These new technologies
that are being created to advance healthcare will allow for new ways for individuals to
seek and obtain healthcare services and at the same time increase the potential for
medical errors to occur. The surgical team has the important tasks of caring for patients
that have put their complete trust in them as professionals. One center is on the right
track, and their results should be copied. When asked about how the center handles
wrong site nerve block errors. Dr. Rasmussen stated,



Weve adopted the surgical model of time-outs prior to every needle stick and
labeling the site of the block prior to patients being sedated at our center. No
training. No workshops. No presentations. Nurses had some input and were familiar
with a similar process. Just workflow change. Nurses have to document exactly what
was done. Nurses drive the process because we have new anesthesiologist who come
from other institutions. Its incumbent on the nurse to follow the procedure that he or
she has on the paperwork and inform the anesthesiologist for the day. So far so good.
And nobody had to endure a lecture, PowerPoint and it respected the current
workflow with some minor changes (M. Rasmussen, personal communication from
26 August 2014)
Easily accepting change is not a concept often applied in healthcare, although it
should be when it is used to increase patient safety. In order for change to happen, the
culture must be willing to adapt to new ideas that will improve the process. The idea that
the old way is the only way is not a concept that healthcare can afford to adopt or hold on
to. In order for the future of healthcare to evolve, the culture must be willing to grow,
adapt, and allow progress that is centered around and improving patient safety. George
Bernard Shaw said it best when he stated, Progress is impossible without change, and
those who cannot change their minds cannot change anything. (, n.d.) It
is time for healthcare to change and make progress towards zero medical errors of any
kind for the future.



Retrieved on 25 August 2014 from:




Table 1

Causes of Wrong-Site Surgeries5, 18, 19, 20

Lack of institutional controls/formal system to verify
the correct site of surgery

Process Factors
Inadequate patient assessment
Inadequate care planning

Lack of a checklist to make sure every check was


Inadequate medical record review

Exclusion of certain surgical team members

Miscommunication among members of

the surgical team and the patient

Reliance solely on the surgeon for determining the

correct surgical site
Unusual time pressures (e.g., unplanned emergencies
or large volume of procedures)
Pressures to reduce preoperative preparation time
Procedures requiring unusual equipment or patient
Team competency and credentialing
Availability of information
Organizational culture

More than one surgeon involved in the

Multiple procedures on multiple parts of
a patient performed during a single
Failure to include the patient and family
or significant others when identifying the
correct site
Failure to mark or clearly mark the
correct operation site

Orientation and training

Incomplete or inaccurate communication

among members of the surgical team


Noncompliance with procedures

Environmental safety/security

Failure to recheck patient information

before starting the operation

Continuum of care
Patient characteristics, such as obesity or unusual
anatomy, that require alterations in the usual
positioning of the patient
From: Chapter 36, Wrong-Site Surgery: A Preventable Medical Error

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Hughes RG, editor.
Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Copyright Notice
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.




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