Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Abstract:

BACKGROUND:Medical errors exact an inordinate toll on healthcare costs. One of the most publicized and analyzed type of medical error is wrong-site surgery. Yet, despite the burgeoning number of procedures performed, no literature exists on wrong-site pain management injections. The purpose of this study was to estimate the relative incidence and determine the causes of wrong-site pain management procedures. METHODS:Quality improvement records were examined during a 2-yr period from four civilian academic teaching hospitals, three military treatment facilities, and three private practices, for "sentinel" events involving wrong-site pain management procedures. A total of 13 cases (incidence 0.027%; 95% CI 0.01-0.05%) were identified from approximately 48,941 collective procedures of which 52.4% were deemed to be "at risk" for the occurrence. Root cause analyses were then conducted to determine the origin of each error. RESULTS:The 13 cases included five wrong-side transforaminal epidural steroid injections, six other wrong-side injections, and two wrong-level minimally invasive surgical procedures. In only one case was the "universal protocol" completely followed, and in nine procedures, multiple lapses occurred in protocol. Three patients had bilateral pathology, and in seven cases, the patient knew at the time that the wrong side was being injected. In no instance did any technical, legal, or professional consequences ensue from the error. CONCLUSIONS:Wrong-site nerve blocks occur more frequently in pain management centers than has previously been acknowledged. Adaptation of the universal protocol to nerve blocks and strict adherence to widely accepted guidelines may prevent wrong-site interventional pain procedures.

journal_name

Anesthesiology

journal_title

Anesthesiology

authors

Cohen SP,Hayek SM,Datta S,Bajwa ZH,Larkin TM,Griffith S,Hobelmann G,Christo PJ,White R

doi

10.1097/ALN.0b013e3181cf892d

subject

Has Abstract

pub_date

2010-03-01 00:00:00

pages

711-8

issue

3

eissn

0003-3022

issn

1528-1175

pii

00000542-201003000-00034

journal_volume

112

pub_type

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