Partnering with Memorial to Prevent Wrong-Site Blocks Before They Occur


Envision Physician Services
Envision Physician Services
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Enhanced recovery after surgery (ERAS) protocols provide significant improvement in recovery time and have been shown to decrease chances of post-op complications and addiction to opioids. However, physicians are also seeing an increased risk of wrong-site nerve blocks within ERAS protocols. Noticing this trend, a group of anesthesiology leaders at Memorial Health System (MHS) developed a strategy to eliminate the potential for wrong-site blocks. After a successful pilot program, the innovative protocols, which rely on visual cues and patient participation, are currently being rolled out across the entire health system.

“We recognized there was a potential problem with our increasing use of ERAS and nerve blocks,” said David Sacks, M.D., Chief of Anesthesiology, Memorial Regional South. “Last year in Florida there were more than 40 wrong-site blocks reported — and in the anesthesia field nationally, these continue to be a problem. It is probably under-reported as well.” Although Memorial Healthcare System (MHS) had never had a wrong-site block occur, Dr. Sacks and Envision Physician Services leaders saw an opportunity to fully prevent these events before they occurred.

An Envision-sponsored Lean process improvement event focused on developing the necessary steps to ensure wrong-site blocks cannot occur. The cross-functional team consisted of Envision physicians Gilbert Drozdow, M.D., Chief Clinical Officer, Joseph Loskove, M.D., Senior Vice President, Anesthesia, Cameron Howard, M.D. and Dr. Sacks. Two registered nurses, Dionne Linton and Dani Cammarata from MHS, also participated in the event.

During the two-day event, the team hypothesized two strategies integral to their solution: visual confirmation of the correct side and a time-out procedure led by the patient.

For visual confirmation, the patient, nurse and physician together place a green wristband on the side corresponding to the surgery. “Sometimes patients change positions when we do nerve blocks, and this can lead to errors,” said Dr. Sacks. “When you see a bright green neon band marked with the word ‘YES’ on the same side as the block, it’s a very strong visual confirmation.”

To standardize time-outs, the patient is provided a script and conducts the meeting to confirm information, including the patient’s allergies, surgery site and block locations. This strategy addresses the potential for mistakes made during time-outs due to clinical fatigue. “Time and productivity pressures can lead physicians to take shortcuts or become distracted during time-outs,” Dr. Sacks said. “When patients lead the time-out, the entire medical team remains focused and engaged.”

The patient-directed time-out not only establishes a powerful, precise confirmation related to the patient and block, it also improves physician focus and overall patient satisfaction.

“When a patient leads a time-out, they receive the total respect of the team. After all, they are the most important person in the process. And the patients like it because they feel confident the team is totally on point. Many patients joke about doing it on the correct side, but it’s a fear that’s really out there.”

Following the Lean event, Dr. Sacks and Adam Blomberg, M.D., Chief of Anesthesiology, MHS, led the implementation of a pilot program at Memorial Regional South, where they used the wristbands and patient-led timeouts for more than 100 patients. “Patients loved it, and it was very effective in identifying and preventing problems,” Dr. Sacks said.

The program was then taken to the MHS Quality and Safety committee for refinement and is currently being released throughout the health system. Serving as our company’s National Education Director, Dr. Blomberg is developing a rollout plan for all Envision Physician Services anesthesiology practices to ensure that wrong-site blocks become a “never occur” event, further protecting our patients, clinicians and health systems.

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