Date of Graduation

Summer 8-9-2022

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

First Advisor

Sara Horton-Deutsch

Abstract

Perioperative registered nurses and anesthesiologists that rely on a process for placing regional anesthesia (R.A.) blocks on the correct side for surgical patients consistently provide high-quality, safe care. Infrequently anesthesiologists place the wrong side peripheral nerve blocks (P.N.B.). Due to the sensitive nature of sentinel events, the frequency of its occurrence at this quality improvement (Q.I.) project site is unavailable. Therefore, a report by Harris et al. (2021) was referenced for the incidence of wrong side blocks (W.S.B.), which were recorded in worldwide, national, and multihospital health care system cohorts as 3.63/10,000, 1.6/10,000, and 1.28/10,000 respectively. The PreOp/PACU nursing staff and the block anesthesiologists reported that doing a pre-procedural time-out with both care providers and maintaining a 1 RN:1 patient ratio makes the procedure safer for patients. These are essential safety measures to protect patients from harm. Before October 2021, adherence to these steps was unrecorded. Potential repercussions of wrong side blocks (W.S.B.) include loss of revenue from payer organizations, defamation of institutional reputation, loss of public trust, and litigation. The goal of this Q.I. project was to maintain a rate of zero W.S.B. in 2022, which is an outcome improvement of 100 percent.

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