Anaesthesia 2015, 70, 997–1010 2. Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2013; 67: 318–40. 3. Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology 2005; 102: 838–54. 4. Hedenstierna G, Edmark L. Mechanisms of atelectasis in the perioperative period. Best Practice & Research Clinical Anaesthesiology 2010; 24: 157–69. 5. Loeckinger A, Kleinsasser A, Keller C, et al. Administration of oxygen before tracheal extubation worsens gas exchange after general anesthesia in a pig model. Anesthesia and Analgesia 2002; 95: 1772–6. 6. Lumb A. Just a little oxygen to breathe as you go off to sleep. is it always a good idea? British Journal of Anaesthesia 2007; 99: 769–71. 7. Ray K, Bodenham A, Paramasivam E. Pulmonary atelectasis in anaesthesia and critical care. Continuing Education in Anaesthesia, Critical Care and Pain 2014; 5: 236–45. 8. Bell MD. Routine pre-oxygenation – a new ‘minimum standard’ of care? Anaesthesia 2004; 59: 943–7. 9. Jubb A, Ford P. Extubation after anaesthesia: a systemic review. Update in Anaesthesia 2009; 25: 30–6. doi:10.1111/anae.13171
Wrong-site surgical blocks Although it is not often that surgeons take a discerning interest in anaesthetic journals, Bower’s experience of a failure in surgical marking has prompted us to draw readers’ attention to one specific change in the list of Never Events for 2015-16 [1, 2], namely the inclusion of wrong-site blocks under the domain of wrong-site surgery, which is of particular relevance to orthopaedic surgeons and anaesthetists. Provisional reports show an increase in the number of wrong-site surgery incidents in the year 2014-15, making 1008
Correspondence
this domain the commonest type of Never Event [3]. We expect this number to increase further with the addition of wrong-site blocks. Possible causes of a wrong-site block include failure of the surgeon to mark the operative side correctly, failure of the anaesthetist to confirm the side of surgery marked pre-operatively by the surgeon, distraction of the anaesthetist, not performing the anaesthetic pre-operative time-out, and discrepancies in the operating list, consent form and patient marking [4]. Many national and local practices have been introduced to tackle the issue as described in Adyanthaya and Patil’s review article [5]. In our experience, a further factor that can contribute to wrong-site blocks is the reliance on a conscious patient, leading to reductions in clinicians’ vigilance. To date, the senior author has been involved in two such events in upper limb surgery, one of which occurred when an allied health professional did not challenge performance of a wrong-side interscalene block (believing it was usually performed from the contralateral side). It would appear that wrong-site blocks in conscious patients are not an uncommon occurrence, with 40% of these errors performed on awake patients in one institution [6]. We welcome the inclusion of wrong-site blocks as Never Events, but highlight the need for maintained vigilance when performing these procedures in the alert patient, in order to help prevent their occurrence.
S. Booth E. M. Holt M. Osbourne University Hospital South Manchester, Manchester, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
References 1. Bowyer A. Wrong site surgical checks; the fallible indelible. Anaesthesia 2012; 67: 193. 2. NHS England Patient Safety Domain. Never Events List 2015/16, 2015. www. england.nhs.uk/wp-content/uploads/ 2015/03/never-evnts-list-15-16.pdf (accessed 10/05/15). 3. NHS England Patient Safety Domain. Provisional publication of never events reported as occurring between 1 April 2014 and March 2015, 2015. www.eng land.nhs.uk/wp-content/uploads/2015/04/ prov-ne-data-apr-mar-15-fin.pdf (accessed 10/05/15). 4. Safe Anaesthesia Liaison Group. Wrong Site Blocks During Surgery, 2010. www. rcoa.ac.uk/system/files/CSQ-PS-10-wrongsite-block.pdf (accessed 10/05/15). 5. Adyanthaya SS, Patil V. Never events: an anaesthetic perspective. Continuing Education in Anaesthesia, Critical Care and Pain 2014; 14: 197–201. 6. Simmons H, Brits R. A survey of anaesthetists’ experiences of wrong-site regional anaesthetics, 2011. www.rcoa. ac.uk/sites/default/files/CSQ-PS-WSBpresentation.pdf (accessed 10/05/15). doi:10.1111/anae.13172
A rule of thumb for estimating the lower confidence interval in trials with small event rates Beach and Sites are to be commended for their instructive work
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Wrong-site surgical blocks Although it is not often that surgeons take a discerning interest in anaesthetic journals, Bower’s experience of a failure in surgical marking has prompted us to draw readers’ attention to one specific change in the list of Never Events for 2015-16 [1, 2], namely the inclusion of wrong-site blocks under the domain of wrong-site surgery, which is of particular relevance to orthopaedic surgeons and anaesthetists. Provisional reports show an increase in the number of wrong-site surgery incidents in the year 2014-15, making 1008
Correspondence
this domain the commonest type of Never Event [3]. We expect this number to increase further with the addition of wrong-site blocks. Possible causes of a wrong-site block include failure of the surgeon to mark the operative side correctly, failure of the anaesthetist to confirm the side of surgery marked pre-operatively by the surgeon, distraction of the anaesthetist, not performing the anaesthetic pre-operative time-out, and discrepancies in the operating list, consent form and patient marking [4]. Many national and local practices have been introduced to tackle the issue as described in Adyanthaya and Patil’s review article [5]. In our experience, a further factor that can contribute to wrong-site blocks is the reliance on a conscious patient, leading to reductions in clinicians’ vigilance. To date, the senior author has been involved in two such events in upper limb surgery, one of which occurred when an allied health professional did not challenge performance of a wrong-side interscalene block (believing it was usually performed from the contralateral side). It would appear that wrong-site blocks in conscious patients are not an uncommon occurrence, with 40% of these errors performed on awake patients in one institution [6]. We welcome the inclusion of wrong-site blocks as Never Events, but highlight the need for maintained vigilance when performing these procedures in the alert patient, in order to help prevent their occurrence.
S. Booth E. M. Holt M. Osbourne University Hospital South Manchester, Manchester, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
References 1. Bowyer A. Wrong site surgical checks; the fallible indelible. Anaesthesia 2012; 67: 193. 2. NHS England Patient Safety Domain. Never Events List 2015/16, 2015. www. england.nhs.uk/wp-content/uploads/ 2015/03/never-evnts-list-15-16.pdf (accessed 10/05/15). 3. NHS England Patient Safety Domain. Provisional publication of never events reported as occurring between 1 April 2014 and March 2015, 2015. www.eng land.nhs.uk/wp-content/uploads/2015/04/ prov-ne-data-apr-mar-15-fin.pdf (accessed 10/05/15). 4. Safe Anaesthesia Liaison Group. Wrong Site Blocks During Surgery, 2010. www. rcoa.ac.uk/system/files/CSQ-PS-10-wrongsite-block.pdf (accessed 10/05/15). 5. Adyanthaya SS, Patil V. Never events: an anaesthetic perspective. Continuing Education in Anaesthesia, Critical Care and Pain 2014; 14: 197–201. 6. Simmons H, Brits R. A survey of anaesthetists’ experiences of wrong-site regional anaesthetics, 2011. www.rcoa. ac.uk/sites/default/files/CSQ-PS-WSBpresentation.pdf (accessed 10/05/15). doi:10.1111/anae.13172
A rule of thumb for estimating the lower confidence interval in trials with small event rates Beach and Sites are to be commended for their instructive work
© 2015 The Association of Anaesthetists of Great Britain and Ireland
