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Response to concerns about block site marking

Last post 20 Oct 2018, 4:57 PM by Jaideep Pandit. 1 replies.
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  •  09 Oct 2018, 4:21 PM 2664

    Response to concerns about block site marking

    Pandit et al. caution against site marking for nerve blocks [1]. NHS Trusts around the country (including our own) have developed local adaptations to the Stop Before You Block (SBYB) procedure, as advocated in the original document [2]. In Oxford, as in other Trusts, we chose to provide a sticker for anaesthetists to use just before performing the procedure as an additional reminder of the site of the block [3] (e.g. if the surgical site mark were distant from the point of insertion of the block). The process we designed seeks to reinforce the vigilance and teamwork within the anaesthetic room when doing the WHO checks.

    The Healthcare Safety Investigation Branch (HSIB) index case [4] described a wrong site block that occurred in a hospital where the local policy was to mark the site with blue tape, but in this case the tape was not applied. This does not provide evidence that applying the mark can lead to wrong site block, but does support the premise put forward by James Reason, that 'misuse of a good rule can lead to error' [5]. The HSIB concluded that 'the current variability of how SBYB is understood and practised means that SBYB does not always form a strong systemic protective barrier to wrong site blocks occurring'. Our own experience in Oxford and evidence from others would support this statement: our current procedures are insufficient to prevent wrong sided blocks.

    It is important to consider what constitutes an 'invasive procedure' and, therefore, how one defines the operator. The 2015 NatSSIPs [6] document states:  '3.4.2 Invasive Procedure: All surgical and interventional procedures performed in operating theatres outpatient treatment areas, labour ward delivery rooms, and other procedural areas within an organisation. In the case of nerve blocks it is commonly an anaesthetist who is the operator responsible for the procedure and, therefore, also responsible for ensuring all sensible measures are taken to perform the block on the correct side. This may include making an additional mark. In the UK, site marking was one of the proposals first made by French et al. [2] who stated 'suggested adjuncts include block side marking by anaesthetists at the time of the WHO sign in'.

    Others have similarly recommended marking of the block site by the anaesthetist to help prevent error, including the Faculty of Pain Medicine at the Royal College of Anaesthetists [7], the American Society for Regional Analgesia [8], the Joint Commission [9], and, most recently, in a systematic review of wrong site blocks by Deutsch et al. [10]. It was also suggested by Professor Pandit that modifications of 'mock before you block' might include signing the site with one's own signature (or other unique mark), or applying a sterile label/dressing to remark the site [11].

    Furthermore, colleagues in interventional radiology have considered the problem of how to ensure procedures are carried out on the correct side such that both the Royal College of Radiologists [12] and the Society of Interventional Radiology [13] recommend site marking. We, therefore, feel that to caution clinicians against site marking now is unhelpful, risking further confusion, and potentially a backward step in attempts to minimise human errors.

    The Canadian Root Cause Analysis Framework states 'from a human factors standpoint, the strongest interventions are physical rather than procedural and permanent rather than temporary' [14]. As yet there is no physical intervention that would absolutely prevent a wrong site nerve block and well designed, standard procedures used properly by everyone are the next best thing.

    We conclude that at the heart of these exchanges of opinion is the desire to ensure that we get it right first time, every time, for our patients and that the available evidence would suggest that a collaborative, multimodal approach will be vital in achieving that end.

    R. Pollard

    H. Higham

    J. Quinlan

    R. Webster

    J. Lie

    S. Sivasubramaniam

    Oxford University Hospitals NHS Trust,

    Oxford, UK.

    Email: rcpollard64@outlook.com


    No external funding and no conflicts of interest declared.



    1. Pandit, JJ, Meek, T, Russell, J. Caution over use of sticker labels or additional marks to create ‘stop’ moment in ‘stop before you block’. Anaesthesia 2018; 73: 1165-75.

    2. French J, Bedforth N, Townsley P. Stop Before You Block Campagn. 2011. www.rcoa.ac.uk/node/631 (accessed 05/10/2018).

    3. Pollard R, Sivasubramaniam S. Stop Before You Block stickers. Anaesthesia 2017; 72: 1156.

    4. Administering a wrong site nerve block - Healthcare Safety Investigation Branch. 2018. https://www.hsib.org.uk/investigations-cases/administering-wrong-site-nerve-block/ (accessed 05/10/2018).

    5. Reason JT. Human Error. Chapter 3: 53-96. Cambridge University Press, 1990.

    6. National Safety Standards for Invasive Procedures (NatSSIPs). https://www.england.nhs.uk/wp-content/uploads/2015/09/natssips-safety-standards.pdf (accessed 05/10/2018).

    7. Faculty of Pain Medicine Safety Checklist for Interventional Pain Procedures. https://www.rcoa.ac.uk/sites/default/files/safety checklist for interventional pain procedures.pdf (accessed 5/10/2018).

    8. Mulroy MF, Weller RS, Liguori GA. A Checklist for Performing Regional Nerve Blocks. Regional Anesthesia and Pain Medicine 2014; 39: 195-9.

    9. Joint Commission T. 2015 National Patient Safety Goals - Hospital Accreditation Program, 2015. https://www.jointcommission.org/standards_information/up.aspx (accessed 05/1020/18)

    10. Deutsch ES, Yonash RA, Martin DE, Atkins JH, Arnold T V., Hunt CM. Wrong-site nerve blocks: A systematic literature review to guide principles for prevention. Journal of Clinical Anesthesia 2018; 46: 101–11.


    11. Pandit JJ, Matthews J, Pandit M. Mock before you block: an in-built action-check to prevent wrong-side anaesthetic nerve blocks. Anaesthesia 2017; 72: 150-5.

    12. Standards for the NPSA and RCR Safety Checklist for Radiological Interventions. https://www.rcr.ac.uk/system/files/publication/field_publication_files/BFCR%2810%2917_NPSA.pdf (accessed 05/10/2018).

    13. Rafiei P, Walser EM, Duncan JR et al. Society of Interventional Radiology IR pre-procedure patient safety checklist by the Safety and Health Committee. Journal of Vascular and Interventional Radiology 2016; 27: 695-9.

    14. Hoffman C, Beard P, Greenall J, U D, White J. Canadian Root Cause Analysis Framework 2006. http://www.patientsafetyinstitute.ca/en/toolsResources/IncidentAnalysis/Documents/Canadian%20Incident%20Analysis%20Framework.PDF (accessed 05/10/2018).

  •  20 Oct 2018, 4:57 PM 2673 in reply to 2664

    Re: Response to concerns about block site marking

    We thank Pollard et al. for observations on our letter [1] and agree with the Health Service Investigation Branch (HSIB) concerns about practice variability in Stop Before You Block (SBYB). The HSIB chose as an index case an example of wrong side block from a Trust that used a sticker, but where this was not applied [2]. The HSIB might equally have used an index case where a sticker was applied on the wrong side, which led to wrong side block. Pollard et al. readily concede that stickers have been ineffective in their experience, so it is unclear if are defending this practice. Additional marks/stickers have caused wrong side blocks and are contrary to other guidance cited, which states the only mark should be the surgical site mark [3].

    Pandit et al. have speculated (before the most recent discussions, and to embrace a wide range of views) about the use of a sign or a sticker, but, crucially, only if these are applied within the sterile field, after skin prep and immediately (just seconds) before needle injection, so as serve as the moment [4]. The alternative described by Pollard et al. involves non-sterile stickers applied long (many minutes) before injection. This cannot serve as a stop moment, but rather only as a reminder. As Hopping et al. discovered, it is not just a case of what forces the stop moment, but when this is applied [5].

    Pollard et al. refer to some international literature, but since practices differ, extrapolation is difficult, especially as Never Events are unique to NHS England [6]. The radiology and other society guidance referred to concerns situations where the block is the sole intervention. That the correspondents extrapolate this to blocks for surgery represents another source of confusion.

    The HSIB has now asked the Safe Anaesthesia Liaison Group (SALG) to review the guidance to resolve inconsistencies. We cannot prejudge the outcome of that review, but checklist fatigue will be one consideration [7]. Mock Before You Block (a personal behavioural barrier) or ultrasound screens (aides memoire) are harmless, at least [1]. It is more difficult to identify those measures which are both harmless and proven effective [8].


    J. J. Pandit

    Chair, Safe Anaesthesia Liaison Group, Royal College of Anaesthetists,

    London, UK.

    T. Meek

    Honorary Secretary, Association of Anaesthetists,

    London, UK.

    Email: jpandit@talk21.com


    No external funding and no conflicts of interest declared.



    1.      Pandit, JJ, Meek, T, Russell, J. Caution over use of sticker labels or additional marks to create ‘stop’ moment in ‘stop before you block’. Anaesthesia 2018; 73: 1165-75.

    2.      Healthcare Safety Investigation Branch. Administering a wrong site nerve block. 2018. https://www.hsib.org.uk/investigations-cases/administering-wrong-site-nerve-block (accessed 05/10/2018).

    3.      NHS England. National Safety Standards for Invasive Procedures (NatSSIPs). Section 4.6. https://www.england.nhs.uk/wp-content/uploads/2015/09/natssips-safety-standards.pdf (accessed 18/10/2018).

    4.       Pandit JJ, Matthews J, Pandit M. “Mock before you block": an in-built action-check to prevent wrong-side anaesthetic nerve blocks. Anaesthesia 2017; 72: 150-5.

    5.      Hopping M, Merry AF, Pandit JJ. Exploring performance of, and attitudes to, Stop- and Mock-Before-You-Block in preventing wrong-side blocks. Anaesthesia 2018; 73: 421-7.

    6.      Pandit JJ. Deaths by horsekick in the Prussian army - and other 'Never Events' in large organisations. Anaesthesia 2016; 71: 7-11.

    7.      Grigg E. Smarter clinical checklists: how to minimize checklist fatigue and maximize clinician performance. Anesthesia and Analgesia 2015; 121: 570-3.

    8.      Pandit JJ, Danbury C. How do we eliminate, or reduce the incidence of, wrong-side anaesthetic blocks? Anaesthesia and Intensive Care 2018; 46: 445-7.

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