A wrong-side nerve block: preparing the M&M case review
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Last week a resident you were supervising performed a left adductor canal block on Mrs. Ellen Price, 68, who was booked for a right total knee replacement. The error was noticed straight after the injection. The correct block was then done, surgery went ahead, and Mrs. Price was kept on fall precautions until her left leg recovered. You and the surgeon disclosed the error to her that day, and an event report was filed. The review found that the time-out was done when she arrived in the block bay, about 30 minutes before the block; she was then sedated, the site mark was under a blanket, and the nurse was called away. The department's morbidity and mortality director, Dr. Lena Ford, has asked to meet you before you present the case.
Your task: discuss the case with Dr. Ford and agree what the department should change. You have 8 minutes; a warning sounds at 6 minutes.4