Wrong-site nerve blocks: a systematic literature review to guide principles for prevention.

Ellen S Deutsch; Robert A Yonash; Donald E Martin; Joshua H Atkins; Theresa Arnold V; Christina M Hunt

Review

Wrong-site nerve blocks: a systematic literature review to guide principles for prevention.

August 8, 2018

Deutsch ES, Yonash RA, Martin DE, et al. J Clin Anesth. 2018;46:101-111.

View more articles from the same authors.

Wrong-site procedures are considered never events, yet they continue to occur. This review describes the incidence, impacts, and contributing factors of wrong-site nerve blocks. The authors recommend verifying the procedure and patient with multiple sources of information, using visible site markings, and employing time outs immediately prior to anesthetic use. A WebM&M commentary discussed an incident involving a wrong-site nerve block.

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Cognitive Errors ("Mistakes")

Wrong-site nerve blocks: a systematic literature review to guide principles for prevention.

A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel.

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