Summer 2010 - The British Pain Society

Papers appraised by Dr Aileen Clyde Pain Fellow Glasgow
PAIN SHORTCUTS
Incidence and Root Cause
Analysis of Wrong-site Pain
Management Procedures
Anesthesiology 2010;112:711-8
The objectives of this study were
to estimate the incidence of wrong
site pain management procedures,
to perform an analysis to identify
the cause of these mistakes and to
publicise the issue of wrong site
surgery and its causes to prevent
further occurrences.
Quality improvement records
were reviewed from pain clinics
at 10 institutions in the USA (
4 academic teaching hospitals,
2 military teaching hospitals, 1
non-academic treatment facility
and 3 private practices) during
a 2 year period from 2007-2009
to identify wrong site procedure
events. All physicians involved in
pain management at each facility
were questioned to identify wrong
site procedures that may not have
been reported. Billing records from
the non-military institutions were
examined and procedure codes
and scheduling records from the
military institutions examine to
identify the total number of pain
procedures carried out in this 2
year period. When multiple distinct
procedures were performed
during a single visit, these were
counted separately. For related
or multilevel procedures that did
not constitute an additional risk of
wrong site surgery, then only the
primary procedure was tabulated.
Individual procedure reports
were examined during a 6 month
period to determine the number
of unilateral procedures or spinal
procedures in which correctly
identifying the pathological level
was deemed to be critically
important. These procedures
were called ‘at risk’ procedures.
Causation was determined by
referring to quality improvement
records and by ‘debriefings’ with
personnel involved in the event.
The review found that 48,941
unrelated procedures were
completed at the 10 institutions
during the 2 year time frame. The
review of 500 billing records along
with daily schedules and electronic
record review indicated 6 duplicate
procedures or procedures that
were not reflected in the billing
records. This gives an estimated
error rate of 1.2%.
13 wrong site procedures were
identified (0.027%; CI 0.01-
0.05%). 12 were from quality
improvement records and 1 from
staff questioning.
The proportion of ‘at risk’
procedures from each institution
ranged from 39-65%, the
weighted average was 52.4%.
Therefore, the incidence of
wrong site procedures was
estimated to be 2.7 per 10,000
pain management procedures
and 5.1 per 10,000 high risk pain
management procedures.
Of the 13 wrong site procedures,
5 were wrong side transforaminal
epidural steroid injections.
There was 1 wrong side facet
radiofrequency denervation, 1
wrong side intercostal nerve radio
frequency ablation, 1 wrong side
intercostal nerve block, 2 wrong
level spinal procedures, 1 wrong
side lumbar sympathectomy, 1
wrong side suprascapular nerve
block and 1 wrong side lumbar
facet injection.
In 5 cases either the side or level
was not noted on the consent
form. In four of the 8 cases where
the consent form was correct, it
was signed by a different person
to that carrying out the procedure.
In one patient the consent form
was not sent with the patient to
the procedure area. A ‘time out’
was performed in only 6 of the 13
cases and the side was marked in
only 2 cases.
The authors identified some
causative factors which appear
to increase the chances of wrong
site surgery. There appeared to
be an increased risk of wrong site
procedures when the responsibility
for safe performance is shifted
between providers, steps in the
‘universal protocol’ are missed,
the site is not marked, bilateral
pathology is present or if a
different practitioner from the
one carrying out the procedure
is involved in obtaining consent.
Strangely in 8 of the 13 cases the
patients knew that the wrong side
Anesthesiology 111(2), August 2009
pp416-431
Intravenous analgesic infusion tests
have been used for some time to
facilitate the management of patients
with chronic pain. The rational
behind their use is that they can
quickly predict who will respond
to a subsequent course of oral
medication, eliminating the time and
expense of an oral medication trial
and reducing the risks of adverse
effects associated with ineffective
drug treatment.
This is the first attempt to review
systematically the literature on
intravenous analgesic infusion tests.
The aim of the systematic review
was to discern the value of these
analgesic drug infusions tests as
prognostic tools in guiding future
drug therapy.
was being targeted. 6 of the 13
patients received sedation for the
procedure.
No legal, professional or
procedural consequence resulted
from the errors although 2
practices determined that the
mistake might lead to future litigation.
No studies like this have been
conducted to determine the
incidence of wrong site pain
procedures in the UK. The WHO
surgical safety checklist, which has
recently been implemented in many
UK hospitals may help to reduce the
problem of wrong site procedures.
It is interesting to note that in many
of the wrong site pain procedures
mentioned in this study, there was
a breach of universal protocol (U.S.
version of surgical safety checklist)
PAIN SHORTCUTS
Intravenous Infusions for
Chronic Pain- a systematic
review
The authors performed a MEDLINE,
EMBASE and OVID search using
appropriate key words. The search
identified 111 published articles on
the subject. Of these 22 articles were
suitable for analysis.
10 studies looked at the predictive
value of lignocaine infusion tests for
treatment with oral sodium channel
blocker mexiletine. Although these
studies are small the data suggests
that a brief lignocaine infusion test is
predictive of subsequent response
to oral mexiletine for patients with
neuropathic pain. There is only
weak evidence that the response to
intravenous lignocaine can predict
response to mexiletine in nociceptive
pain. The authors point out that the
long term effectiveness of mexiletine
therapy remains in question as a
result of its significant side effect
profile, mainly nausea and sedation.
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PAI N N E W S S U M M E R 2010