1
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Ha J. Preventing wrong-sided blocks. Int Anesthesiol Clin 2024; 62:53-57. [PMID: 38404146 DOI: 10.1097/aia.0000000000000436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Affiliation(s)
- Jihye Ha
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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2
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Haslam N, Bedforth N, Pandit JJ. 'Prep, stop, block': refreshing 'stop before you block' with new national guidance. Anaesthesia 2021; 77:372-375. [PMID: 34904710 DOI: 10.1111/anae.15647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 12/01/2022]
Affiliation(s)
- N Haslam
- Department of Anaesthesia, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - N Bedforth
- Department of Anaesthesia, Nottingham University Hospital NHS Trust, Nottingham, UK.,University of Nottingham, Nottingham, UK
| | - J J Pandit
- Department of Anaesthesia, Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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3
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Kim JY, Moore MR, Culwick MD, Hannam JA, Webster CS, Merry AF. Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS. Anaesth Intensive Care 2021; 50:204-219. [PMID: 34871511 DOI: 10.1177/0310057x211027578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.
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Affiliation(s)
- Jee Young Kim
- Department of Anaesthesia and Perioperative Medicine, 58991Auckland City Hospital, Auckland City Hospital, Auckland, New Zealand
| | - Matthew R Moore
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Martin D Culwick
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jacqueline A Hannam
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Craig S Webster
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Alan F Merry
- Department of Anaesthesia and Perioperative Medicine, 58991Auckland City Hospital, Auckland City Hospital, Auckland, New Zealand.,Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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4
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Chiew A, Saw C, Seet E, Kumar CM. Anaesthetist-administered wrong-side eye blocks: need to reinforce clearer guidelines and site marking. Br J Anaesth 2021; 127:e151-e154. [PMID: 34489091 DOI: 10.1016/j.bja.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/05/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alyssa Chiew
- Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore
| | - Cheryl Saw
- Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore
| | - Edwin Seet
- Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore
| | - Chandra M Kumar
- Department of Anaesthesia, Khoo Teck Puat Hospital, Singapore.
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5
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Harris SN, Ortolan SC, Edmonds CR, Fields KG, Liguori GA. Fewer Wrong-Site Peripheral Nerve Blocks Following Updates to Anesthesia Time-Out Policy. HSS J 2021; 17:180-184. [PMID: 34421428 PMCID: PMC8361586 DOI: 10.1177/1556331621993079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/04/2020] [Indexed: 11/15/2022]
Abstract
Background: Peripheral nerve block (PNB) has been shown to be safe and effective, and its use has continued to increase, but it is not without risks. One potentially preventable risk is wrong-site blocks (WSBs). Our institution mandated a time-out process before PNB in 2003, and then in 2007 made two more changes to our policy to mitigate risk: (1) the circulating/block nurse was the only person permitted to access the block needles; after a time-out period was complete, the nurse gave the needles to the anesthesiologist; and (2) the nurse remained at the patient's bedside until the PNB was initiated. Purpose: We sought to compare the incidence of WSBs before and after this time-out process was implemented in 2003 and the enhanced form of it was implemented in 2007. We hypothesized that the enhanced process would decrease the incidence of WSBs. Methods: We retrospectively analyzed data, from January 2003 to December 2016, taken from the quality assurance and performance improvement (QA/PI) division of the anesthesiology department at our institution, which maintained daily statistics on anesthetic types using quality audits from paper or electronic anesthesia records. All WSBs from this period were reported to the QA/PI division and root cause analyses performed. The incidence of WSB was compared pre- and post-implementation of the enhanced time-out policy for upper extremity, lower extremity, and all blocks by calculating relative risks with 95% score confidence intervals and performing Fisher's exact tests. Results: The incidence of WSBs decreased from 1.10/10,000 before changes to the policy were initiated to 0.24/10,000 afterward. Conclusion: We observed an association between the implementation of a dynamic, team-focused time-out process and a reduction in the incidence of WSBs at our institution. A causal effect of the enhanced time-out cannot be determined given the risk of bias associated with before-after study designs and our lack of adjustment for potential confounders. Further research is therefore warranted.
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Affiliation(s)
- Stephen N. Harris
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Sarah C. Ortolan
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
- Sarah C. Ortolan, MS, Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021, USA.
| | - Chris R. Edmonds
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Kara G. Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Gregory A. Liguori
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
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6
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Olivarius-McAllister J, Pandit M, Sykes A, Pandit JJ. How can Never Event data be used to reflect or improve hospital safety performance? Anaesthesia 2021; 76:1616-1624. [PMID: 33932033 DOI: 10.1111/anae.15476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
The absolute number of Never Events is used by UK regulators to help assess hospital safety performance, without account of hospital workload. We applied funnel plots, as an established means of taking workload into account, to published Never Event data for 151 acute Trusts in NHS England, matched to finished consultant episodes for 3 years, 2017-2020. Trusts with excess event rates should have the most Never Events if absolute number is a valid way to judge performance. The absolute number of Never Events was correlated with workload (r2 = 0.51, p < 0.001), but the five Trusts above the upper 95% confidence limit did not have the highest number of Never Events. However, a limitation to interpretation was that the data were skewed; 12 out of 151 Trusts lay below the lower 95% limit. This skew probably arises because funnel plots pool all Never Events and workload data; whereas, ideally, different Never Events should use as denominator only the relevant workload actions that could cause them. We conclude that the manner in which Never Event data are currently used by regulators, in part to judge or rate hospitals, is mathematically invalid. The focus should shift from identifying 'outlier' hospitals to reducing the overall national mean Never Event rate through shared learning and an integrated system-wide approach.
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Affiliation(s)
- J Olivarius-McAllister
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Pandit
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Sykes
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J J Pandit
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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7
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Kwofie K, Uppal V. Wrong-site nerve blocks: evidence-review and prevention strategies. Curr Opin Anaesthesiol 2020; 33:698-703. [PMID: 32826627 DOI: 10.1097/aco.0000000000000912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW There has been increasing attention to wrong site medical procedures over the last 20 years. This review aims to provide a summary of the current understanding and recommendations for the prevention of wrong-site nerve blocks (WSNB). RECENT FINDINGS Various procedural, patient, practitioner, and organizational factors have been associated with the risk of WSNB. Recent findings have suggested that the use of a checklist is likely to reduce the incidence of WSNB. However, despite the widespread use of preprocedural checklists, WSNB continue to occur at significant frequency. This may be due to the inability of practitioners and teams to implement checklists correctly or the cognitive errors that prevent checklists from being executed as designed. SUMMARY Though the evidence is limited, it is recommended that a combination of multiple strategies should be employed to prevent WSNB. These include the use of preprocedural markings, well constructed checklists, time-out/stop-moments, and cognitive/physical aids. Effective implementation requires team education and engagement that empowers all team members to speak up as part of a culture of safety.
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Affiliation(s)
- Kwesi Kwofie
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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8
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Sivia DS, Pandit JJ. Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue. Anaesthesia 2019; 74:992-1000. [DOI: 10.1111/anae.14629] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - J. J. Pandit
- Nuffield Department of Anaesthesia Oxford University Hospitals NHS Trust Oxford UK
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9
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Johnstone C, Razavi C, Pawa A, Onwochei DN, Vargulescu R. A practical solution for preventing wrong-side blocks. Anaesthesia 2019; 73:914. [PMID: 29889995 DOI: 10.1111/anae.14353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C Johnstone
- Guy's and St, Thomas' NHS Foundation Trust, London, UK
| | - C Razavi
- Guy's and St, Thomas' NHS Foundation Trust, London, UK
| | - A Pawa
- Guy's and St, Thomas' NHS Foundation Trust, London, UK
| | - D N Onwochei
- Guy's and St, Thomas' NHS Foundation Trust, London, UK
| | - R Vargulescu
- Guy's and St, Thomas' NHS Foundation Trust, London, UK
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10
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Affiliation(s)
- J. J. Pandit
- Safe Anaesthesia Liaison Group; Royal College of Anaesthetists; London UK
| | - T. Meek
- Association of Anaesthetists; London UK
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Affiliation(s)
| | - T. Meek
- South Tees Hospitals NHS Foundation Trust; Middlesborough UK
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12
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Pandit JJ, Danbury C. How Do We Eliminate, Or Reduce the Incidence Of, Wrong-Side Anaesthetic Blocks? Anaesth Intensive Care 2018; 46:445-447. [DOI: 10.1177/0310057x1804600502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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13
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Pandit JJ, Meek T, Russell J. Caution over use of sticker labels or additional marks to create ‘stop’ moment in ‘stop before you block’. Anaesthesia 2018; 73:1165-1166. [DOI: 10.1111/anae.14404] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- J. J. Pandit
- Safe Anaesthesia Liaison Group; Royal College of Anaesthetists; London UK
| | - T. Meek
- Association of Anaesthetists; London UK
| | - J. Russell
- Patient Safety, Policy and Partnerships; NHS Improvement; London UK
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14
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Brennan C, Gormley GJ, Corry R. The importance of human factors in right-left errors. Anaesthesia 2018; 73:790. [DOI: 10.1111/anae.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- C. Brennan
- Centre of Medical Education; Queen's University Belfast; Belfast UK
| | - G. J. Gormley
- Centre of Medical Education; Queen's University Belfast; Belfast UK
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Affiliation(s)
- I K Moppett
- Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - S T Shorrock
- Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Qld, Australia
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