The scene

An anaesthetic trainee contacted the MDU advice line following an adverse incident. The trainee had administered an anaesthetic nerve block to a patient who was undergoing a procedure on their wrist, but had inadvertently injected the left side rather than the right.

The trainee noticed his error immediately and let the surgeon know. The block was repeated on the right side and the procedure went ahead without complication. The surgeon explained what had happened to the patient, who was happy with the explanation and did not intend to take the matter any further.

The trainee was anxious about what would happen next and whether there was anything he needed to do.

MDU advice

The national guidance and safety recommendations that exist to prevent this type of error occurring should be in place, and as a result this incident would be referred to as a 'never event'. Hospital trusts have a duty to report never events and investigate them to ensure learning takes place to prevent future harm.

As well as the patient being informed about what had happened and being offered an apology, the MDU's medico-legal adviser recommended the trainee to report this through the hospital's reporting system, and to discuss it with their educational supervisor.

The adviser explained that the trust would be obliged to formally investigate the incident in order to review systems and to establish how they could be improved. The aim of such investigations should not be to apportion blame, but if an employee knowingly failed to report what had happened when a never event occurred, this failure could result in disciplinary action.

In preparation for the investigation, the adviser recommended the trainee prepare a draft statement that the MDU could review. The statement needed to be a factual account of what happened, written in an open and transparent way, including as much detail as possible, explaining the process and checks the trainee went through before administering the block and whether there were any distractions at the time. They told the trainee that they may be interviewed as part of the trust's investigation and should be given a copy of the minutes of that meeting.

The adviser emphasised the importance of reflecting on clinical incidents and learning from them by suggesting the trainee review the Healthcare Safety Investigation Branch (HSIB) report on administering wrong site nerve blocks and engage in some relevant professional development in anticipation of the investigation. They also advised the trainee send a copy of the draft statement to the MDU along with a copy of the anonymised clinical records, so further support and advice could be provided in the future.

Wrong side anaesthetic block

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