RCoA responds to HSIB report on wrong site anaesthetic nerve block

Published: 13/09/2018

Dr William Harrop-Griffiths, Chair of the College’s Clinical Quality and Research Board said:

“The Royal College of Anaesthetists welcomes the publication of the Healthcare Safety Investigation Branch’s (HSIB) report on Wrong Site Anaesthetic Nerve Block and fully accepts the recommendations made.

“We have already started developing a working group to evaluate current practices with the aim of minimising the incidence of further wrong site blocks. The group will also examine the human factors that increase the chances of wrong site block including patient position changes during procedures.

“The College will take forward any work recommended by the group and ensure that human factors testing and evaluation form a key element in trialling any new or modified procedures.

“The College, as a member of the Safe Anaesthesia Liaison Group, championed the 2011 introduction of the ‘Stop Before You Block’ campaign in response to an increased number of reports of wrong site blocks. This HSIB report has clearly highlighted the fact that these errors continue to occur and that it is time to re-evaluate clinician’s use of the ‘Stop Before You Block’ check, to see how it can be improved in order to make patient care safer.”