Royal College of Anaesthetists
We recommend that The Royal College of Anaesthetists establishes a specialist working group to evaluate the current practices used to reduce wrong site block incidents. This group should consider how safety initiatives to reduce wrong site blocks can be standardised in anaesthesia training and practice. It is recommended that the specialist working group consider the impact of: the patient’s state of consciousness, changes in a patient’s position and the prevalence of wrong site block incidents compared to the number of blocks administered.
We recommend that The Royal College of Anaesthetists ensures any further work identified by the specialist working group to reduce wrong site block incidents is subject to human factors-based testing and evaluation.
The Royal College of Anaesthetists welcomes the publication of the Healthcare Safety Investigation Branch’s (HSIB’s) report on Wrong Site Anaesthetic Nerve Block and supports the recommendation made that the College establishes a working party to evaluate current practices with a view to achieving standardisation.
In response, the College and the Association of Anaesthetists, working through the Safe Anaesthesia Liaison Group, will develop a specialist working group with key stakeholders to evaluate current practices with the aim of minimising the incidence of wrong site blocks. The group will also examine the human factors that increase the chances of wrong site block including patient position changes during procedures. The College will then take forward any work recommended by the group and ensure that human factors testing and evaluation form a key element in trialling any new or modified procedures.
Combined response to both safety recommendations received on 7 November 2018.