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Downloaded from https://academic.oup.com/milmed/article/183/9-10/e281/4938791 by DeepDyve user on 20 July 2022 MILITARY MEDICINE, 183, 9/10:e281, 2018 LAST Double Check – A Comprehensive Pre-Regional Checklist for the Busy Institution CPT Angelica G. Mancone, MC, USA*; Capt Alyssa R. Dickey, USAF, MC*; Lt Col Brian M. Fitzgerald, USAF, MC†; MAJ Gregory P. Kraus, MC, USA†; MAJ Sandeep T. Dhanjal, MC, USA† ABSTRACT Introduction: Wrong site peripheral nerve blocks are included in the National Quality Forum and Joint Commission’s category of “never event.” Multiple attempts have been made by various groups in an effort to eliminate these events. Prior attempts to eliminate these never events include the Regional Block Preprocedural Checklist pro- vided by the American Society of Regional Anesthesia (ASRA) taskforce. Following a series of errors involving antic- oagulation prior to regional anesthesia, our department saw a need for a more comprehensive checklist. Materials and Methods: An expert panel developed the LAST Double Check Checklist with the aim of identifying and eliminating errors associated with regional anesthesia delivery. This checklist was implemented over the course of two 30 d trial periods. Feedback was collected and any delays associated with implementation were recorded. Results: There were no reported procedures performed on patients taking anticoagulation or reported case delays during the two 30 d trials. A total of 350 regional anesthetics were performed during both trials. During the ﬁrst week of implementation, a patient was identiﬁed as having received enoxaparin, despite the electronic medical record showing the medication as held. The planned regional anesthetic was not performed given increased risk of bleeding. Feedback collected during the trial periods was incorporated into the ﬁnal draft and implementation of the LAST Double Check for use in all locations where regional anesthesia is performed. There have been no post-implementation events reported (11-mo period, greater than 1,000 regional anesthetics performed). Conclusion: The LAST Double Check is a more comprehensive checklist with the aim of preventing errors associated with wrong site blocks, anticoagulation administration, and care team coordination. This checklist covers areas of the patient history that are routinely reviewed prior to regional anes- thesia administration and did not contribute to delay in arrival to the operating room. INTRODUCTION occurrence, from the World Health Organization’s Safe Surgical “And these two things in disease are particularly to be Checklist, TJC’s Universal Protocol, Nottingham University’s attended to, to do good, and not to do harm.” “Stop Before You Block Campaign,” the “Mock before you block” proposal from Wight et al., and a pediatric-speciﬁc -Hippocrates, The History of Epidemics 4–9 regional checklist from Clebone et al. Given the abundance of checklists available, a taskforce was appointed by the Wrong site surgery is considered by The Joint Commission American Society of Regional Anesthesia (ASRA) in 2013 (TJC) to be a sentinel event, and its occurrence is never to attempt to consolidate some of the existing checklists, acceptable or justiﬁable. Hence the term “never event” was the product of which was the “Regional Block Preprocedural created, along with it an implicit push to eliminate them Checklist.” completely. Wrong site peripheral nerve blocks are included In addition to wrong-sided nerve blocks, there are multiple in this category, since they are invasive procedures that can other potential errors that can occur while performing regional lead to serious and permanent harm. It is no surprise, there- anesthesia, to include issues stemming from anticoagulation, fore, that extreme efforts have been taken to prevent their the correct block being performed for the planned surgery, and the understanding of the nature of the block in reference to *Department of Anesthesia, Anesthesiology Residency, San Antonio its ability to serve as a surgical anesthetic or supplemental Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., JBSA Ft. Sam Houston, TX 78234. adjunct. The potential for error is complicated by the fact that †Department of Anesthesia, San Antonio Uniformed Services Health there are often numerous teams caring for the same patient, Education Consortium, 3551 Roger Brooke Dr., JBSA Ft. Sam Houston, including the block team, surgeons, and the anesthesia pro- TX 78234. vider in the room. A busy operating room schedule with short The views expressed herein are those of the authors and do not reﬂect turnover time and a lack of standardized processes make the ofﬁcial policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Ofﬁce of the Surgeon General, adverse events inevitable. Unfortunately, adverse events the Department of the Army, the Department of the Air Force, and regarding regional anesthesia can be disastrous and poten- Department of Defense or the U.S. Government. tially permanent for the patient. doi: 10.1093/milmed/usx220 As guidelines and electronic medical record documenta- Published by Oxford University Press on behalf of the Association of tion grow ever larger, the need for clear protocols becomes Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. apparent, or error will be inevitable. Such was the case at MILITARY MEDICINE, Vol. 183, September/October 2018 e281 Downloaded from https://academic.oup.com/milmed/article/183/9-10/e281/4938791 by DeepDyve user on 20 July 2022 LAST Double Check our institution, where regional anesthesia procedures were nerve blocks performed outside of the regional bay. (See inadvertently performed on patients taking anticoagulation. Fig. 2). Thankfully, no complications arose from these occurrences, Several poster-sized checklists were also created to be dis- but these events highlighted an area with need for improve- played in the regional bay listing generic and trade names of ment. Despite the abundance of available guidelines and common anticoagulation and antiplatelet agents. (See Fig. 3). checklists, we determined there was a need in our institution for a more speciﬁc checklist with an emphasis on anticoagula- Staff Brieﬁng tion. Given these occurrences, we aimed to compose a checklist The department of anesthesia was briefed at a staff meeting that would address regional anesthetics and anticoagulation, regarding the background and implementation of the LAST with the goal of completely eliminating regional techniques Double Check Checklist. Members were encouraged to use performed unknowingly on patients receiving anticoagulation. the checklist and to provide feedback for improvement. They were also informed that the regional bay nurse would be record- ing case delays caused by its implementation. METHODS Using our institution’s patient safety reporting system, retro- spective review over a 1-yr period identiﬁed two instances Trials where regional anesthesia was performed while on anticoa- During the ﬁrst week of implementation, a patient was noted gulation. Both instances involved thoracic epidurals placed to have received enoxaparin the morning of surgery. in patients taking enoxaparin. This excluded patients taking Notably, the medication was documented as “held” in the known anticoagulation medication on whom regional anesthesia electronic medical record, however when the patient was was performed after a risk-beneﬁts discussion, in accordance questioned according to the checklist, she reported receiving with ASRA guidelines. Given the occurrence of these events, an enoxaparin injection in her abdomen that morning. The an expert panel convened to compose a mechanism to prevent planned regional anesthetic was not performed due to the future regional anesthetic errors. The LAST Double Check increased bleeding risk. Checklist was formed, with the intention that this checklist be employed before every regional anesthetic performed in the Checklist Revision regional bay. This checklist was then implemented in two sepa- During implementation, several suggestions were made to rate 30 d trials. Feedback was sought from point of care users to include adding areas for documentation of co-morbidities include several experts in regional anesthesia, and modiﬁcation and patient contact information. Additionally, spaces were was made based on received feedback. Delays in arrival to the added for block performed and sedation used, to help with operating room attributed to the checklist were also monitored procedure notes written on particularly busy days. throughout the trials. The above processes comprised two rendi- tions of the Plan-Do-Study-Act (PDSA) cycle (See Fig. 1). Of note, after this project was initiated to address these RESULTS issues and before the implementation of the checklist, two Trials additional regional anesthetics were performed on patients There were no reported procedures performed on patients taking anticoagulation. These involved a thoracic epidural taking anticoagulation or reported case delays during the two and a sciatic catheter. The anticoagulant for these instances 30 d trials. A total of 350 regional anesthetics were per- was also enoxaparin. In total, four instances were reported formed during both trials. (See Table 1) over an approximately 3-yr period. Post-Implementation Checklist There have been no post-implementation events reported (11 Using existing pre-regional guidelines, a checklist was designed mo period, greater than 1,000 regional anesthetics performed). to meet our institution’s needs, with a focus on anticoagulation. We wanted a checklist that would be easy to remember, to promote ease of usage, especially if the hard copy was not DISCUSSION readily available. The name LAST Double Check was created, Our institution is a major military treatment facility and a as LAST is an abbreviation already strongly associated with level one trauma center serving the southern Texas region. regional anesthesia in reference to local anesthetic systemic There are over 25 ﬁrst start surgeries daily, including both toxicity. “Double Check” is also a play on words to help with emergent and elective procedures; many of these patients are memory recall, as the LAST mnemonic is doubled. candidates for regional anesthesia. Each patient is cared for The checklist was printed on letter size paper, laminated, by multiple providers in various areas of patient care through and placed in the regional bay along with erasable markers. their perioperative experience, to include our pre-admission Additionally, badge-sized cards were printed to be attached unit, prep and hold, regional bay, operating room, and ﬁnally the to hospital identiﬁcation badges for ease of reference for post-anesthesia care unit. Most commonly, regional anesthesia e282 MILITARY MEDICINE, Vol. 183, September/October 2018 Downloaded from https://academic.oup.com/milmed/article/183/9-10/e281/4938791 by DeepDyve user on 20 July 2022 LAST Double Check FIGURE 1. Plan-Do-Study-Act cycles. These depict the steps involved in the planning and implementation of this quality improvement project. The goal of the creation of this checklist goes beyond ensur- ing the right procedure for the right patient, but rather aims to be a comprehensive check that several crucial requirements have been met. For that reason, nil per os (NPO) status and beta-human chorionic gonadotropin (beta-HCG) results have been included. This checklist also attempts to help close some of the gaps in management that may occur due to trans- fer of the patient between multiple care teams, as listed under the “Talk to Team” heading. The impetus for the creation of this checklist was the inad- vertent performance of several regional anesthetics on patients who were taking anticoagulation, which was unknown to the team at the time of the procedure. The complexity of our elec- tronic medical record may be a contributing factor to this occurrence, as there are multiple locations where anticoagula- tion may be documented, and this differs for inpatient versus outpatient surgery. For this reason, the checklist prompts users to check the various locations and to also question the patient directly. Direct questioning resulted in one “catch” of adminis- tered anticoagulation that was erroneously documented in the medication ﬂowsheet. It is not clear if this would have been caught without the checklist. Several modiﬁcations were made to this checklist for optimal usage at our institution after the ﬁrst PSDA cycle, such as the procedure details listed at the bottom of page. This checklist can FIGURE 2. LAST Double Check Badge Cards. The checklist was printed and distributed on badge-sized cards for ease of reference. easily be tailored to meet other institutions’ speciﬁcneeds. As a military institution, we recognize the potential use of this checklist in a deployed setting. We feel that the mne- procedures are performed in the regional bay where a dedi- monics used lead to quick recall, which would be particu- cated nurse is present. However, procedures may be performed larly useful in a stressful situation or when resources are in the operating room (before or after induction), in the post- limited and the checklist is not available. anesthesia care unit, on the wards/intensive care units, in the The limitations of this checklist include the absence of a pain clinic, and occasionally in the emergency department. The prompt to re-perform the time-out in patients receiving mul- “block team” is typically composed of one to two anesthesiol- tiple nerve blocks, as have been included in other checklists. ogy residents and one attending anesthesiologist. MILITARY MEDICINE, Vol. 183, September/October 2018 e283 Downloaded from https://academic.oup.com/milmed/article/183/9-10/e281/4938791 by DeepDyve user on 20 July 2022 LAST Double Check FIGURE 3. LAST Double Check Poster. Posters with checklist and common antiplatelet and anticoagulant agents were displayed in the regional bay. used for site veriﬁcation of any additional blocks. An addi- TABLE I. Regional Anesthetics Performed tional potential limitation is the extra time required to perform Regional Procedure First Trial Second Trial Total the checklist, however all of the steps listed are typically per- Adductor Canal 57 71 128 formed – the checklist serves as a visual and physical repre- Ankle 1 1 2 sentation of those steps, and prevents inadvertently omitting a Axillary 1 2 3 step. Epidural 1 4 5 This quality improvement project is further limited by the Fascia Iliaca 0 5 5 relatively short length of the trial periods and the short over- Femoral 9 4 13 Intercostobrachial 11 6 17 all implementation period thus far. However, given the rarity Interscalene 19 27 46 of these adverse events a signiﬁcantly longer implementation Lumbar Plexus 0 1 1 period would be required. Median 0 1 1 Paravertebral 4 1 5 Radial 0 1 1 Sciatic 30 38 68 CONCLUSION SPANK 03 3 The LAST Double Check Checklist was designed as the Superﬁcial Cervical Plexus 1 2 3 result of breaches of ASRA guidelines, but its potential uses Supraclavicular 29 15 44 Transverse Abdominis Plane 3 2 5 go beyond that. We believe this checklist can easily be Total 166 184 350 implemented at other institutions to address multiple aspects of patient safety, and can be tailored to meet institutions’ Totals are given for each trial and overall. unique needs. It also has potential use in the deployed set- Bilateral procedures counted once. Sensory posterior articular nerves of the knee. ting. To all physicians, patient safety is of utmost impor- tance, and is the foundation of our profession. From the ancient words of Hippocrates comes the well-known phrase, As Wight points out, however, there has never been an occur- “ﬁrst, do no harm.” The concept is just as relevant today as rence of two sequential wrong-sided nerve blocks, which sug- it was then. When it comes to patient safety, there is no such gests that if the correct laterality is performed the ﬁrst time, thing as being too careful, and it is never wrong to double any additional blocks will also be on the correct side. The ﬁrst check. “S” in “LAST” refers to supplemental block, and this can be e284 MILITARY MEDICINE, Vol. 183, September/October 2018 Downloaded from https://academic.oup.com/milmed/article/183/9-10/e281/4938791 by DeepDyve user on 20 July 2022 LAST Double Check 7. Slocombe P, Pattullo S: A site check prior to regional anaesthesia to REFERENCES prevent wrong-sided blocks. Anaesth Intensive Care 2016; 44(4): 1. Johns Hopkins Sheridan Libraries: Oaths and Codes. 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Military Medicine – Oxford University Press
Published: Sep 1, 2018
Keywords: anticoagulation; anesthesia, conduction; anesthetics; enoxaparin; operating room; electronic medical records; feedback; never event; surgical checklist; peripheral block anesthesia; risk of excessive or recurrent bleeding; national quality forum; coordination; medical history
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