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 provided by the American Society of Regional Anesthesia (ASRA) taskforce. Following a series of errors involving anticoagulation 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 anesthesia administration and did not contribute to delay in arrival to the operating room. INTRODUCTION “And these two things in disease are particularly to be attended to, to do good, and not to do harm.” -Hippocrates, The History of Epidemics1 Wrong site surgery is considered by The Joint Commission (TJC) to be a sentinel event, and its occurrence is never acceptable or justifiable.2 Hence the term “never event” was created, along with it an implicit push to eliminate them completely.3 Wrong site peripheral nerve blocks are included in this category, since they are invasive procedures that can lead to serious and permanent harm. It is no surprise, therefore, that extreme efforts have been taken to prevent their occurrence, from the World Health Organization’s Safe Surgical Checklist, TJC’s Universal Protocol, Nottingham University’s “Stop Before You Block Campaign,” the “Mock before you block” proposal from Wight et al., and a pediatric-specific regional checklist from Clebone et al.4–9 Given the abundance of checklists available, a taskforce was appointed by the American Society of Regional Anesthesia (ASRA) in 2013 to attempt to consolidate some of the existing checklists, the product of which was the “Regional Block Preprocedural Checklist.”10 In addition to wrong-sided nerve blocks, there are multiple other potential errors that can occur while performing regional anesthesia, to include issues stemming from anticoagulation, the correct block being performed for the planned surgery, and the understanding of the nature of the block in reference to its ability to serve as a surgical anesthetic or supplemental adjunct. The potential for error is complicated by the fact that there are often numerous teams caring for the same patient, including the block team, surgeons, and the anesthesia provider in the room. A busy operating room schedule with short turnover time and a lack of standardized processes make adverse events inevitable. Unfortunately, adverse events regarding regional anesthesia can be disastrous and potentially permanent for the patient. As guidelines and electronic medical record documentation grow ever larger, the need for clear protocols becomes apparent, or error will be inevitable. Such was the case at our institution, where regional anesthesia procedures were inadvertently performed on patients taking anticoagulation. Thankfully, no complications arose from these occurrences, but these events highlighted an area with need for improvement. Despite the abundance of available guidelines and checklists, we determined there was a need in our institution for a more specific checklist with an emphasis on anticoagulation. Given these occurrences, we aimed to compose a checklist that would address regional anesthetics and anticoagulation, with the goal of completely eliminating regional techniques performed unknowingly on patients receiving anticoagulation. METHODS Using our institution’s patient safety reporting system, retrospective review over a 1-yr period identified two instances where regional anesthesia was performed while on anticoagulation. Both instances involved thoracic epidurals placed in patients taking enoxaparin. This excluded patients taking known anticoagulation medication on whom regional anesthesia was performed after a risk-benefits discussion, in accordance with ASRA guidelines.11 Given the occurrence of these events, an expert panel convened to compose a mechanism to prevent future regional anesthetic errors. The LAST Double Check Checklist was formed, with the intention that this checklist be employed before every regional anesthetic performed in the regional bay. This checklist was then implemented in two separate 30 d trials. Feedback was sought from point of care users to include several experts in regional anesthesia, and modification was made based on received feedback. Delays in arrival to the operating room attributed to the checklist were also monitored throughout the trials. The above processes comprised two renditions of the Plan-Do-Study-Act (PDSA) cycle (See Fig. 1). FIGURE 1. View largeDownload slide Plan-Do-Study-Act cycles. These depict the steps involved in the planning and implementation of this quality improvement project. FIGURE 1. View largeDownload slide Plan-Do-Study-Act cycles. These depict the steps involved in the planning and implementation of this quality improvement project. Of note, after this project was initiated to address these issues and before the implementation of the checklist, two additional regional anesthetics were performed on patients taking anticoagulation. These involved a thoracic epidural and a sciatic catheter. The anticoagulant for these instances was also enoxaparin. In total, four instances were reported over an approximately 3-yr period. Checklist Using existing pre-regional guidelines, a checklist was designed 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 readily available. The name LAST Double Check was created, as LAST is an abbreviation already strongly associated with regional anesthesia in reference to local anesthetic systemic toxicity. “Double Check” is also a play on words to help with memory recall, as the LAST mnemonic is doubled. The checklist was printed on letter size paper, laminated, and placed in the regional bay along with erasable markers. Additionally, badge-sized cards were printed to be attached to hospital identification badges for ease of reference for nerve blocks performed outside of the regional bay. (See Fig. 2). FIGURE 2. View largeDownload slide LAST Double Check Badge Cards. The checklist was printed and distributed on badge-sized cards for ease of reference. FIGURE 2. View largeDownload slide LAST Double Check Badge Cards. The checklist was printed and distributed on badge-sized cards for ease of reference. Several poster-sized checklists were also created to be displayed in the regional bay listing generic and trade names of common anticoagulation and antiplatelet agents. (See Fig. 3). FIGURE 3. View largeDownload slide LAST Double Check Poster. Posters with checklist and common antiplatelet and anticoagulant agents were displayed in the regional bay. FIGURE 3. View largeDownload slide LAST Double Check Poster. Posters with checklist and common antiplatelet and anticoagulant agents were displayed in the regional bay. Staff Briefing The department of anesthesia was briefed at a staff meeting regarding the background and implementation of the LAST Double Check Checklist. Members were encouraged to use the checklist and to provide feedback for improvement. They were also informed that the regional bay nurse would be recording case delays caused by its implementation. Trials During the first week of implementation, a patient was noted to have received enoxaparin the morning of surgery. Notably, the medication was documented as “held” in the electronic medical record, however when the patient was questioned according to the checklist, she reported receiving an enoxaparin injection in her abdomen that morning. The planned regional anesthetic was not performed due to the increased bleeding risk. Checklist Revision During implementation, several suggestions were made to include adding areas for documentation of co-morbidities and patient contact information. Additionally, spaces were added for block performed and sedation used, to help with procedure notes written on particularly busy days. Results Trials 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. (See Table 1) Table I. Regional Anesthetics Performed Regional Procedure First Trial Second Trial Total Adductor Canal 57 71 128 Ankle 1 1 2 Axillary 1 2 3 Epidural 1 4 5 Fascia Iliaca 0 5 5 Femoral 9 4 13 Intercostobrachial 11 6 17 Interscalene 19 27 46 Lumbar Plexus 0 1 1 Median 0 1 1 Paravertebral 4 1 5 Radial 0 1 1 Sciatic 30 38 68 SPANKa 0 3 3 Superficial Cervical Plexus 1 2 3 Supraclavicular 29 15 44 Transverse Abdominis Plane 3 2 5 Total 166 184 350 Regional Procedure First Trial Second Trial Total Adductor Canal 57 71 128 Ankle 1 1 2 Axillary 1 2 3 Epidural 1 4 5 Fascia Iliaca 0 5 5 Femoral 9 4 13 Intercostobrachial 11 6 17 Interscalene 19 27 46 Lumbar Plexus 0 1 1 Median 0 1 1 Paravertebral 4 1 5 Radial 0 1 1 Sciatic 30 38 68 SPANKa 0 3 3 Superficial Cervical Plexus 1 2 3 Supraclavicular 29 15 44 Transverse Abdominis Plane 3 2 5 Total 166 184 350 Totals are given for each trial and overall. Bilateral procedures counted once. aSensory posterior articular nerves of the knee. Table I. Regional Anesthetics Performed Regional Procedure First Trial Second Trial Total Adductor Canal 57 71 128 Ankle 1 1 2 Axillary 1 2 3 Epidural 1 4 5 Fascia Iliaca 0 5 5 Femoral 9 4 13 Intercostobrachial 11 6 17 Interscalene 19 27 46 Lumbar Plexus 0 1 1 Median 0 1 1 Paravertebral 4 1 5 Radial 0 1 1 Sciatic 30 38 68 SPANKa 0 3 3 Superficial Cervical Plexus 1 2 3 Supraclavicular 29 15 44 Transverse Abdominis Plane 3 2 5 Total 166 184 350 Regional Procedure First Trial Second Trial Total Adductor Canal 57 71 128 Ankle 1 1 2 Axillary 1 2 3 Epidural 1 4 5 Fascia Iliaca 0 5 5 Femoral 9 4 13 Intercostobrachial 11 6 17 Interscalene 19 27 46 Lumbar Plexus 0 1 1 Median 0 1 1 Paravertebral 4 1 5 Radial 0 1 1 Sciatic 30 38 68 SPANKa 0 3 3 Superficial Cervical Plexus 1 2 3 Supraclavicular 29 15 44 Transverse Abdominis Plane 3 2 5 Total 166 184 350 Totals are given for each trial and overall. Bilateral procedures counted once. aSensory posterior articular nerves of the knee. Post-Implementation There have been no post-implementation events reported (11 mo period, greater than 1,000 regional anesthetics performed). DISCUSSION Our institution is a major military treatment facility and a level one trauma center serving the southern Texas region. There are over 25 first start surgeries daily, including both emergent and elective procedures; many of these patients are candidates for regional anesthesia. Each patient is cared for by multiple providers in various areas of patient care through their perioperative experience, to include our pre-admission unit, prep and hold, regional bay, operating room, and finally the post-anesthesia care unit. Most commonly, regional anesthesia procedures are performed in the regional bay where a dedicated nurse is present. However, procedures may be performed in the operating room (before or after induction), in the post-anesthesia care unit, on the wards/intensive care units, in the pain clinic, and occasionally in the emergency department. The “block team” is typically composed of one to two anesthesiology residents and one attending anesthesiologist. The goal of the creation of this checklist goes beyond ensuring 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 transfer 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 inadvertent 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 electronic medical record may be a contributing factor to this occurrence, as there are multiple locations where anticoagulation 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 administered 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 easily be tailored to meet other institutions’ specific needs. As a military institution, we recognize the potential use of this checklist in a deployed setting. We feel that the mnemonics used lead to quick recall, which would be particularly useful in a stressful situation or when resources are limited and the checklist is not available. The limitations of this checklist include the absence of a prompt to re-perform the time-out in patients receiving multiple nerve blocks, as have been included in other checklists. As Wight points out, however, there has never been an occurrence of two sequential wrong-sided nerve blocks, which suggests that if the correct laterality is performed the first time, any additional blocks will also be on the correct side.8 The first “S” in “LAST” refers to supplemental block, and this can be used for site verification of any additional blocks. An additional potential limitation is the extra time required to perform the checklist, however all of the steps listed are typically performed – the checklist serves as a visual and physical representation of those steps, and prevents inadvertently omitting a step. This quality improvement project is further limited by the relatively short length of the trial periods and the short overall implementation period thus far. However, given the rarity of these adverse events a significantly longer implementation period would be required. Conclusion The LAST Double Check Checklist was designed as the result of breaches of ASRA guidelines, but its potential uses go beyond that. We believe this checklist can easily be implemented at other institutions to address multiple aspects of patient safety, and can be tailored to meet institutions’ unique needs. It also has potential use in the deployed setting. To all physicians, patient safety is of utmost importance, and is the foundation of our profession. From the ancient words of Hippocrates comes the well-known phrase, “first, do no harm.” The concept is just as relevant today as it was then. When it comes to patient safety, there is no such thing as being too careful, and it is never wrong to double check. References 1 Johns Hopkins Sheridan Libraries : Oaths and Codes. Available at http://guides.library.jhu.edu/c.php?g=202502&p=1334891; accessed July 20, 2017. 2 The Joint Commission : Sentinel event policy and procedures. Available at https://www.jointcommission.org/sentinel_event_policy_and_procedures/; accessed July 20, 2017. 3 Thiels CA , Lal TM , Nienow JM , et al. : Surgical never events and contributing human factors . Surgery 2015 ; 158 ( 2 ): 515 – 21 . Google Scholar CrossRef Search ADS PubMed 4 World Health Organizatio : WHO surgical safety checklist. Available at http://www.who.int/patientsafety/safesurgery/checklist/en/; accessed July 20, 2017. 5 Barrington MJ , Uda Y , Pattullo SJ , Sites BD : Wrong-site regional anesthesia: review and recommendations for prevention? Curr Opin Anaesthesiol 2015 ; 28 ( 6 ): 670 – 84 . Google Scholar CrossRef Search ADS PubMed 6 The Royal College of Anaesthetists : Wrong Site Block. Available at http://www.rcoa.ac.uk/standards-of-clinical-practice/wrong-site-block; accessed July 20, 2017. 7 Slocombe P , Pattullo S : A site check prior to regional anaesthesia to prevent wrong-sided blocks . Anaesth Intensive Care 2016 ; 44 ( 4 ): 513 – 16 . Google Scholar PubMed 8 Wight JM , Chrisman L , Reed I , et al. : Mock before you block . Anaesthesia 2017 ; 72 ( 5 ): 661 – 62 . Google Scholar CrossRef Search ADS PubMed 9 Clebone A , Burian BK , Polaner DM : A time-out checklist for pediatric regional anesthetics . Reg Anesth Pain Med 2017 ; 42 ( 1 ): 105 – 08 . Google Scholar CrossRef Search ADS PubMed 10 Mulroy MF , Weller RS , Liguori GA : A checklist for performing regional nerve blocks . Reg Anesth Pain Med 2014 ; 39 ( 3 ): 195 – 99 . Google Scholar CrossRef Search ADS PubMed 11 Narouze S , Benzon HT , Provenzano DA , et al. : Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain . Reg Anesth Pain Med 2015 ; 40 ( 3 ): 182 – 212 . Google Scholar CrossRef Search ADS PubMed Author notes The views expressed herein are those of the authors and do not reflect 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, the Department of the Army, the Department of the Air Force, and Department of Defense or the U.S. Government. Published by Oxford University Press on behalf of the Association of 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.
Military Medicine – Oxford University Press
Published: Sep 1, 2018