Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.
BACKGROUND
Although wrong-site surgery has garnered extensive scrutiny, the incidence of wrong-site blocks remains unknown. Our study thus sought to quantify the incidence of wrong-site blocks and examine some of their associated risk factors in our multihospital health-care system.


METHODS
Using quality-improvement and billing data, we quantified the total number of blocks and wrong-site blocks occurring between July 1, 2002 and June 30, 2012 within the University of Pittsburgh Medical Center Health System. The incidence of wrong-site block was determined by block type, hospital, and type of service involved in performing the block. The incidence of wrong-site block was compared with that of wrong-site surgery. Fisher's exact tests were performed to determine associations between the incidence of wrong-site block and any of the aforementioned variables. A root-cause analysis was performed to determine the source of wrong-site blocks after the implementation of a timeout policy.


RESULTS
Of the 85 915 patients receiving blocks, 70 441 received only unilateral blocks, yielding an overall incidence of wrong-site block of 1.28 (95% confidence interval 0.43-2.13) per 10 000 patients receiving unilateral blocks. The incidence of wrong-site block was highest with femoral blocks, and differed from the incidence of wrong-site surgery. All occurrences of wrong-site block after the implementation of the timeout policy involved policy violations.


CONCLUSIONS
Our study provides the first incidence data on wrong-site block in a large patient population and can help hospitals to develop policies based on these data. It is yet to be determined whether active intervention can eliminate this adverse event.
Department of Anesthesiology, University of Pittsburgh School of Medicine, University of Pittsburgh Physicians, Pittsburgh, PA, USA hudsonme@anes.upmc.edu.
M E
ME
Hudson
Department of Anesthesiology, University of Pittsburgh School of Medicine, University of Pittsburgh Physicians, Pittsburgh, PA, USA.
J E
JE
Chelly
Department of Anesthesiology, University of Pittsburgh School of Medicine, University of Pittsburgh Physicians, Pittsburgh, PA, USA.
J R
JR
Lichter
D006801:Humans; D008508:Medication Errors / Q000706:statistics & numerical data*; D009407:Nerve Block / Q000379:methods / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care / Q000379:methods* / Q000706:statistics & numerical data*
medical errors; nerve block; quality assurance, health-care