A clinician prepares a nerve block injection.

Administering a wrong site nerve block

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

This investigation seeks to identify opportunities and systemic remedies to reduce the risk of wrong site anaesthetic nerve blocks occurring. Anaesthetic nerve blocks are injections to block pain in a specific region of the body.

Please note that this investigation has previously been known as 'wrong site interventions'.

Investigation summary

We were notified of an incident that took place at a specialist NHS orthopaedic centre in 2017. A 69-year-old man undergoing elective surgery on his right ankle had a nerve block administered to his left leg.

The investigation focuses on:

  • The Stop Before You Block process and its use nationally.
  • Specific distractions arising from this particular incident that impacted on the anaesthetic team.

Stop Before You Block is a national patient safety initiative that aims to reduce the incidence of inadvertent wrong-sided nerve block during regional anaesthesia.

Although the investigation and the report focus primarily on wrong site anaesthetic blocks, the findings, safety recommendations and safety observation may be beneficial when considering the development of other national patient safety initiatives.

Investigation report