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We read with interest Harris and Torlot’s letter [1] surveying the use of site marking for peripheral nerve blockade in Wessex. We agree that although the incidence of wrong-sided regional blocks is rare, it is something one would certainly like to avoid.
At our institution we use two practices concurrently to ensure that the correct side of the patient receives peripheral nerve blockade. First, a 'Site-marking' is performed. Coloured painters’ tape is placed circumferentially around the limb to be anesthetised (Figure 1). Then, a 'Time-out' is performed with the anaesthetist, the nurse, and the awake patient. Both practices occur before regional block placement and before any sedation is administered. We also recommend doing the 'Time-out' with the patient placed in the position that the regional block is to be performed (e.g. prone).
The advantages of the 'Site-marking' are many. The circumferential nature of the marking eliminates confusion when the patient is marked in the supine position, and then later is positioned prone for regional block placement (and vice versa). The tape is visible from all angles, and requires no adjustments during patient re-positioning. Another advantage is the marking of the limb to be anesthetised, and not the actual location of the regional block. As stated in Harris and Torlot’s correspondence, the regional block site is often distant from the actual surgical site. Finally, our tape happens to be royal blue, which has led to an easy to remember 'catch phrase' regarding the marking protocol: 'No blue, no block'. Limb marking is now mandatory for all patients receiving regional blockade in our practice.
The 'Time-out' procedure is used in conjunction with marking, and acts to further ensure patient safety. Before the placement of the regional block, the anaesthetist, the nurse, and the awake patient verify the patient’s identity, surgery site, and peripheral nerve block to be performed. This method requires co-ordination and agreement between anaesthetist, nurse, and patient. Involvement of the nursing staff provides additional clinical oversight to reduce the risk of error. 'Time-out' also satisfies the Joint Commission requirements for Universal Protocol [2].
In combination, these practices provide clear identification easily recognised by all clinicians involved with the regional procedure, including the patient. Nursing involvement and teamwork is encouraged, facilitating regional block placement and safety. Furthermore, when the patient enters the operating theatre, this method provides yet another identification of the surgical site. Finally, our process is inexpensive and efficient.
These practices were implemented in 2006 by J. Eric Greensmith, MD, PhD, after our institution had similar incidents of patients receiving peripheral nerve blockade on the incorrect side. Although these events were quiterare, they did prompt the change in practice and policy. Since that time, over 7 500 peripheral nerve blocks have been performed, with no errors with regard to regional block location or patient identification. Based on our experience we strongly recommend the use of 'Site-marking' and the 'Time-out' procedures before performing regional nerve blockade.
J. C. Chi
S. Sathishkumar
Penn State Hershey Medical Center
Hershey, Pennsylvania, USA
E-mail: jchi@hmc.psu.edu
References
1 Harris B, Torlot K. Site marking byanaesthetists preparing for peripheral nerve blockade. Anaesthesia 2010; 65:312.
2 The Joint Commission. Accreditation Program: Hospital. National Patient Safety Goals.2009. Available from http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/HAP_NPSG.pdf(accessed 12 August 2009).
Figure 1
Blue painter’s tape is wrapped around the limb to be blocked. This marker is unaffected by the patient’s position, and is easily identified from all angles.
