Safe Anaesthesia

Stop and Check – The Human Problem…

Here at SBYB Safe, we have been putting a lot of thought into how ‘never events’ such as wrong site anaesthetic block come about.

In 2010, Nottingham University Hospitals, in conjunction with the Safe Anaesthesia Liaison Group and Regional Anaesthesia (UK), analysed and published details about 67 wrong-site anaesthetic block events over a 15-month period. The result was the creation of the ‘Stop Before You Block’ Campaign, a joint project to institute a mandatory ‘stop’ event prior to the insertion of the anaesthetic block needle in order to confirm the site and laterality of the injection.

Since then, wrong-site block has featured as one of the Never Events monitored by the English National Health Service (NHS), with mandatory reporting to NHS Improvement for all events. Statistics regarding these events are publicly accessible on the NHS Improvement website.

Of note, wrong-site block continues to occur with alarming frequency despite the campaign, resulting in cancelled operations, unnecessary procedures, delays in treatment and direct harm to the patient. Costs have been estimated to be on average in the region of £200,000 per event, through adverse patient outcomes and prolonged hospital stay, compensation for harm, lost operating theatre time, investigations and other excess resource utilisation.

So how can clinicians be encouraged to confirm something with an extra step, which doesn’t improve outcomes for most patients, only the unfortunate few, and where the attitude may be that ‘It’s NOT going to happen to ME’?

Incentives or punishments, i.e. ‘carrots or sticks’, only work with independent observation of the clinician through audit work, which is likely to be sporadic and expensive.

The broader remit of culture change has been a successful approach in operating theatres, demonstrated most strikingly by the almost universal take-up of the World Health Organisation (WHO) surgical safety checklist in the UK. However, convincing evidence that the WHO checklist has improved patient outcomes is still lacking.

We at SBYB Safe believe that we have found the key to block laterality checking. We call this ‘Giving the Clinician something Useful in Return’.

We have incorporated an injection pressure monitoring system, which enables the clinician to objectively measure the pressure on injection of local anaesthetic. High injection pressures may be due to needle-tip positioning within the nerve, and injection of local anaesthetic directly into the nerve is associated with temporary or permanent neuronal damage. Accurate needle-tip visualisation using the ultrasound probe is operator-skill dependent and our device is valuable in giving extra information to the anaesthetist regarding the safety of the injection. It is a useful device providing real-time information of interest to anaesthetists and so we anticipate high take up of the device.

Through this device and its features of a pressure monitoring device that is activated only when the anaesthetist has reconfirmed the block site, we believe that we can make an important difference in enhancing the safety of this form of anaesthesia, for the benefit of all patients as well as for the health organisation.

In future, producers of other regional anaesthesia products such as ultrasound scanners may wish to incorporate a block-checking feature on their devices, but so far they have been reluctant to do so. In the meantime, there is SBYB Safe.