| Recommendation | Contributing factor(s) addressed |
- Perform a separate time-out immediately before administering a block, involving active verification by at least two team members and the patient, when possible
| - Inadequate time-out protocol
- Poor adherence to time-out
- Verbal/written communication breakdown
|
- Adopt a standardized, facility-wide policy for marking the operative eye that involves the same unambiguous and enduring mechanism used by all providers within the facility
| - Variation in surgical site marking procedures
- Verbal/written communication breakdown
|
- Strengthen credentialing and orientation processes for new, contracted, and locum tenens anesthesia staff, including clear internal assessment criteria and standardized questions to be evaluated by qualified staff and adequate onboarding that reviews elements such as a facility's work flow, site-marking policy, and time-out procedures
| - New staff/trainee involved in procedure
- Insufficient training in block administration
- Poor adherence to time-out
- Variation in surgical site marking procedures
- Verbal/written communication breakdown
- Staff hesitancy to voice concerns
|
- Observe the initial blocks of any anesthesia provider who is new to a facility, and require that they have adequate and documented training, both didactic and clinical, on proper technique, management of complications, and identification of high-risk patients
| - Insufficient training in block administration
- New staff/trainee involved in procedure
- Inherent risks associated with needle-based blocks
|
- Use the least invasive form of anesthesia that is appropriate for the patient and case, considering the patient's preferences and comorbidities, the planned procedure, and potential complications
| - Inherent risks associated with needle-based blocks
- Insufficient training in block administration
|
- Stay current on evidence-based practices for minimizing the risk of harm from anesthesia, and avoid relying on personal experience to assess the relative safety of techniques
| - Inherent risks associated with needle-based blocks
|
