• Safety watchdog questions whether ‘Stop Before you Block’ patient safety campaign is working
  • HSIB found variations in compliance across different NHS trusts
  • Royal College of Anaesthetists will establish a specialist working group to evaluate the practice

The Healthcare Safety Investigation Branch has questioned whether a national patient safety initiative has had any impact on wrongly-administered anaesthetics.

The new safety watchdog published its third report focussed on “system-wide issues”, which was prompted by the administration of an anaesthetic on the wrong leg of a 69-year-old man at an acute NHS trust.

The investigation considered the factors that led to the patient receiving the wrong-site nerve block and also reviewed the efficacy of the ‘Stop Before you Block’ campaign, which was launched in 2011 with the aim of encouraging anaesthetists to double check a surgical site marking before inserting a block needle.

The HSIB team observed similar anaesthetic procedures in “several NHS trusts” and witnessed “variations in practice and compliance with the national and local guidance”.

The investigation found that it was “unclear” whether the national safety campaign has had any impact on the incidence of wrong-site nerve blocks.

It also said the ‘Stop Before you Block’ campaign did not provide “sufficient clarity or direction” on how it should be used and there is “significant variation” in its uptake.

HSIB recommended that the Royal College of Anaesthetists establishes a specialist working group to evaluate current practices and consider how safety initiatives can be standardised.

It also said that the development of patient safety is subject to “human factors-based” testing and evaluation.

William Harrop-Griffiths, chair of the Royal College of Anaesthetists’ clinical quality and research board, said the college welcomed HSIB’s report and “fully accepts” the recommendations.

Dr Harrop-Griffiths said: “The college 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 check.”

He added: “We have already started developing a working group to evaluate current practices with the aim of minimising the incidence of further wrong site blocks.”