4.7 Stop Before You Block & Never events Flashcards
a) List the implications for the patient of an inadvertent wrong-sided peripheral nerve block. (5 marks)
> > Potential adverse effects of unnecessary nerve block (including infection,
bleeding, nerve damage, visceral damage).
> > Bilateral block may be contraindicated (e.g. interscalene), resulting in
cancellation of surgery, suboptimal pain relief or experience of side
effects of the alternative pain relief.
> > Safe doses of local anaesthesia may be exceeded if correct side
subsequently blocked.
> > May result in wrong-sided surgery.
> > Delayed discharge due to immobility if nerve blocks therefore undertaken
on both legs.
> > Loss of trust.
b) Summarise the recommendations of the ‘Stop Before You Block’ campaign (4 marks),
> > Educate staff, ensure cooperation of all staff, especially anaesthetists and
ODPs.
> > After WHO checklist, STOP just before needle insertion.
> > ODP and anaesthetist to:
• Visualise arrow indicating the laterality of surgery.
• Check laterality with patient if conscious, consent form if not.
• Confirm site and side of block.
List factors that have been identified as contributing to the performance of a wrong-side block. (5 marks)
> > Long duration since WHO sign-in.
> > Patient being turned prone or lateral.
> > Busy anaesthetic room; anaesthetist distracted.
> > Lower limb blocks: arrow may not be immediately visible if patient
covered for warmth or dignity.
> > Anaesthetist not regularly performing blocks.
c) Define the term ‘never event’ (2 marks) and
Never events are serious incidents that are entirely preventable because
guidance or safety recommendations providing strong systemic protective
barriers are available at a national level and should have been implemented
by all healthcare providers
list four drug-related never events. (4 marks)
> > Mis-selection of a strong potassium-containing solution.
> > Wrong route administration of medication.
> > Overdose of insulin due to abbreviations or incorrect device.
> > Overdose of methotrexate for non-cancer treatment.
> > Mis-selection of high-strength midazolam during conscious sedation.
> > Unintentional connection of patient requiring oxygen to an air flowmeter.
list four drug-related never events. (4 marks)
> > Mis-selection of a strong potassium-containing solution.
> > Wrong route administration of medication.
> > Overdose of insulin due to abbreviations or incorrect device.
> > Overdose of methotrexate for non-cancer treatment.
> > Mis-selection of high-strength midazolam during conscious sedation.
> > Unintentional connection of patient requiring oxygen to an air flowmeter.
Extensive list of never events
Large proportion involve anaesthesia and drug administration. Some of
them could be the basis of a future question.
> > Wrong site surgery (includes wrong site block).
Wrong implant/prosthesis.
> > Retained foreign object post-operation.
> > Mis-selection of a strong potassium-containing solution.
> > Wrong route administration of medication.
> > Overdose of insulin due to abbreviations or incorrect device.
> > Overdose of methotrexate for non-cancer treatment.
> > Mis-selection of high-strength midazolam during conscious sedation.
> > Failure to install functional collapsible shower or curtain rails.
> > Falls from poorly restricted windows.
> > Chest or neck entrapment in bedrails.
> > Transfusion or transplantation of ABO-incompatible blood components
or organs.
> > Misplaced naso- or orogastric tube.
Scalding of patients.
> > Unintentional connection of patient requiring oxygen to an air flowmeter.
> > Undetected oesophageal intubation.
