LAST Double Check – A Comprehensive Pre-Regional Checklist for the Busy Institution

MILITARY MEDICINE, 183, 9/10:e281, 2018 LAST Double Check – A Comprehensive Pre-Regional Checklist for the Busy Institution CPT Angelica G. Mancone, MC, USA*; Capt Alyssa R. Dickey, USAF, MC*; Lt Col Brian M. Fitzgerald, USAF, MC†; MAJ Gregory P. Kraus, MC, USA†; MAJ Sandeep T. Dhanjal, MC, USA† INTRODUCTION “And these two things in disease are particularly to be attended to, to do good, and not to do harm.” -Hippocrates, The History of Epidemics1 Wrong site surgery is considered by The Joint Commission (TJC) to be a sentinel event, and its occurrence is never acceptable or justifiable.2 Hence the term “never event” was created, along with it an implicit push to eliminate them completely.3 Wrong site peripheral nerve blocks are included in this category, since they are invasive procedures that can lead to serious and permanent harm. It is no surprise, therefore, that extreme efforts have been taken to prevent their *Department of Anesthesia, Anesthesiology Residency, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., JBSA Ft. Sam Houston, TX 78234. †Department of Anesthesia, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., JBSA Ft. Sam Houston, TX 78234. The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, and Department of Defense or the U.S. Government. doi: 10.1093/milmed/usx220 Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. MILITARY MEDICINE, Vol. 183, September/October 2018 occurrence, from the World Health Organization’s Safe Surgical Checklist, TJC’s Universal Protocol, Nottingham University’s “Stop Before You Block Campaign,” the “Mock before you block” proposal from Wight et al., and a pediatric-specific regional checklist from Clebone et al.4–9 Given the abundance of checklists available, a taskforce was appointed by the American Society of Regional Anesthesia (ASRA) in 2013 to attempt to consolidate some of the existing checklists, the product of which was the “Regional Block Preprocedural Checklist.”10 In addition to wrong-sided nerve blocks, there are multiple other potential errors that can occur while performing regional anesthesia, to include issues stemming from anticoagulation, the correct block being performed for the planned surgery, and the understanding of the nature of the block in reference to its ability to serve as a surgical anesthetic or supplemental adjunct. The potential for error is complicated by the fact that there are often numerous teams caring for the same patient, including the block team, surgeons, and the anesthesia provider in the room. A busy operating room schedule with short turnover time and a lack of standardized processes make adverse events inevitable. Unfortunately, adverse events regarding regional anesthesia can be disastrous and potentially permanent for the patient. As guidelines and electronic medical record documentation grow ever larger, the need for clear protocols becomes apparent, or error will be inevitable. Such was the case at e281 ABSTRACT Introduction: Wrong site peripheral nerve blocks are included in the National Quality Forum and Joint Commission’s category of “never event.” Multiple attempts have been made by various groups in an effort to eliminate these events. Prior attempts to eliminate these never events include the Regional Block Preprocedural Checklist provided by the American Society of Regional Anesthesia (ASRA) taskforce. Following a series of errors involving anticoagulation prior to regional anesthesia, our department saw a need for a more comprehensive checklist. Materials and Methods: An expert panel developed the LAST Double Check Checklist with the aim of identifying and eliminating errors associated with regional anesthesia delivery. This checklist was implemented over the course of two 30 d trial periods. Feedback was collected and any delays associated with implementation were recorded. Results: There were no reported procedures performed on patients taking anticoagulation or reported case delays during the two 30 d trials. A total of 350 regional anesthetics were performed during both trials. During the first week of implementation, a patient was identified as having received enoxaparin, despite the electronic medical record showing the medication as held. The planned regional anesthetic was not performed given increased risk of bleeding. Feedback collected during the trial periods was incorporated into the final draft and implementation of the LAST Double Check for use in all locations where regional anesthesia is performed. There have been no post-implementation events reported (11-mo period, greater than 1,000 regional anesthetics performed). Conclusion: The LAST Double Check is a more comprehensive checklist with the aim of preventing errors associated with wrong site blocks, anticoagulation administration, and care team coordination. This checklist covers areas of the patient history that are routinely reviewed prior to regional anesthesia administration and did not contribute to delay in arrival to the operating room. LAST Double Check METHODS Using our institution’s patient safety reporting system, retrospective review over a 1-yr period identified two instances where regional anesthesia was performed while on anticoagulation. Both instances involved thoracic epidurals placed in patients taking enoxaparin. This excluded patients taking known anticoagulation medication on whom regional anesthesia was performed after a risk-benefits discussion, in accordance with ASRA guidelines.11 Given the occurrence of these events, an expert panel convened to compose a mechanism to prevent future regional anesthetic errors. The LAST Double Check Checklist was formed, with the intention that this checklist be employed before every regional anesthetic performed in the regional bay. This checklist was then implemented in two separate 30 d trials. Feedback was sought from point of care users to include several experts in regional anesthesia, and modification was made based on received feedback. Delays in arrival to the operating room attributed to the checklist were also monitored throughout the trials. The above processes comprised two renditions of the Plan-Do-Study-Act (PDSA) cycle (See Fig. 1). Of note, after this project was initiated to address these issues and before the implementation of the checklist, two additional regional anesthetics were performed on patients taking anticoagulation. These involved a thoracic epidural and a sciatic catheter. The anticoagulant for these instances was also enoxaparin. In total, four instances were reported over an (...truncated)