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New Prep, Stop, Block guidance for blocks close to the midline

New Prep, Stop, Block guidance for blocks close to the midline Wrong site peripheral nerve block is classified in the National Health Service (NHS) as a never event [1]. Stop Before You Block (SBYB), introduced by Regional Anaesthesia‐UK (RA‐UK) and the Safe Anaesthesia Liaison Group (SALG), was a national patient safety initiative designed to prevent wrong site nerve blocks [2]. Following an investigation by the Healthcare Safety Investigation Branch, SALG and RA‐UK recently updated the SBYB initiative, refreshing it with the new Prep, Stop, Block (PSB) framework [3, 4]. Wrong site block is listed by NHS Improvement as an intervention that ‘is considered to be surgical’ and, although the list refers specifically to wrong site surgery, the examples given are of wrong side surgery: ‘wrong knee, eye, limb’[1]. These are all errors of laterality and the structures are obviously either right or left sided.A recent case of wrong sided erector spinae plane (ESP) catheter placement at our institution resulted in a wrong site block where there was no clear and obvious error of laterality, and where we do not feel it would have been reasonable to expect the assistant to have spotted the error due to the proximity of the block to the midline.When performing an ESP block, a longitudinal http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Anaesthesia Reports Wiley

New Prep, Stop, Block guidance for blocks close to the midline

Hussien, E.; Chuter, E.; Haslam, N.
Anaesthesia Reports , Volume 10 (2) – Jul 1, 2022
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Publisher
Wiley
Copyright
2022 © Association of Anaesthetists
eISSN
2637-3726
DOI
10.1002/anr3.12186
Publisher site
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Abstract

Wrong site peripheral nerve block is classified in the National Health Service (NHS) as a never event [1]. Stop Before You Block (SBYB), introduced by Regional Anaesthesia‐UK (RA‐UK) and the Safe Anaesthesia Liaison Group (SALG), was a national patient safety initiative designed to prevent wrong site nerve blocks [2]. Following an investigation by the Healthcare Safety Investigation Branch, SALG and RA‐UK recently updated the SBYB initiative, refreshing it with the new Prep, Stop, Block (PSB) framework [3, 4]. Wrong site block is listed by NHS Improvement as an intervention that ‘is considered to be surgical’ and, although the list refers specifically to wrong site surgery, the examples given are of wrong side surgery: ‘wrong knee, eye, limb’[1]. These are all errors of laterality and the structures are obviously either right or left sided.A recent case of wrong sided erector spinae plane (ESP) catheter placement at our institution resulted in a wrong site block where there was no clear and obvious error of laterality, and where we do not feel it would have been reasonable to expect the assistant to have spotted the error due to the proximity of the block to the midline.When performing an ESP block, a longitudinal

Journal

Anaesthesia Reports – Wiley

Published: Jul 1, 2022

Keywords: nerve block: landmarks; peripheral nerves: anatomy

References

  • Prep, stop, block: refreshing ‘stop before you block’ with new national guidance
    Haslam, N; Bedforth, N; Pandit, JJ