Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.
BACKGROUND
Medical errors exact an inordinate toll on healthcare costs. One of the most publicized and analyzed type of medical error is wrong-site surgery. Yet, despite the burgeoning number of procedures performed, no literature exists on wrong-site pain management injections. The purpose of this study was to estimate the relative incidence and determine the causes of wrong-site pain management procedures.


METHODS
Quality improvement records were examined during a 2-yr period from four civilian academic teaching hospitals, three military treatment facilities, and three private practices, for "sentinel" events involving wrong-site pain management procedures. A total of 13 cases (incidence 0.027%; 95% CI 0.01-0.05%) were identified from approximately 48,941 collective procedures of which 52.4% were deemed to be "at risk" for the occurrence. Root cause analyses were then conducted to determine the origin of each error.


RESULTS
The 13 cases included five wrong-side transforaminal epidural steroid injections, six other wrong-side injections, and two wrong-level minimally invasive surgical procedures. In only one case was the "universal protocol" completely followed, and in nine procedures, multiple lapses occurred in protocol. Three patients had bilateral pathology, and in seven cases, the patient knew at the time that the wrong side was being injected. In no instance did any technical, legal, or professional consequences ensue from the error.


CONCLUSIONS
Wrong-site nerve blocks occur more frequently in pain management centers than has previously been acknowledged. Adaptation of the universal protocol to nerve blocks and strict adherence to widely accepted guidelines may prevent wrong-site interventional pain procedures.
Cohen
Steven P
SP
Department of Anesthesiology and Critical Care Medicine, Blaustein Pain Treatment Center, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. scohen40@jhmi.edu
Hayek
Salim M
SM
Datta
Sukdeb
S
Bajwa
Zahid H
ZH
Larkin
Thomas M
TM
Griffith
Scott
S
Hobelmann
Greg
G
Christo
Paul J
PJ
White
Ronald
R
D000328:Adult; D000368:Aged; D005260:Female; D017408:Guidelines as Topic; D006772:Hospitals, Military; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000191:economics / Q000706:statistics & numerical data*; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D009407:Nerve Block / Q000009:adverse effects* / Q000191:economics; D010146:Pain / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology*; D018710:Pain Clinics; D011785:Quality Assurance, Health Care; D014481:United States / Q000453:epidemiology