Development of performance and error metrics for ultrasound-guided axillary brachial plexus block

Figures & data

Figure 1 A view from a video recording presented to the MG to aid procedure characterization. Views are from the operative procedure and ultrasound output.

Abbreviation: MG, metric group.

Table 1 Six phases of the procedure characterization and abbreviated summary of the definitions of the 54 performance metrics developed by the MG and validated by the Delphi panel

A. Initial patient interaction

1. Place patient on a suitable trolley or bed

2. Establish conversation with the patient

3. Perform safe surgical checklist

4. Establish an intravenous cannula

5. Establish monitoring

6. Give sedative medication

7. Administer supplemental oxygen

B. Procedure ergonomics

8. Adjust equipment within workplace

9. Remove clothing from arm

10. Expose patients arm

11. Place arm in block position

C. Aseptic preparation (patient, operator, equipment)

12. Ensure operator arms are bare

13. Decontaminates hands

14. Wear sterile gloves

15. Prepare block tray

16. Prepare a high-frequency ultrasound probe

17. Prepare local anesthetics solution

18. Confirm name and expiry date of local anesthetics

19. Flush block needle

20. Decontaminate skin of the axilla

21. Establish sterile field by using sterile drapes

22. Fix sterile drapes

D. Ultrasonography

23. Check sidedness of the ultrasound probe

24. Place probe on the axilla

25. Hold probe in a tripod grip

26. Confirm identity of axillary artery

27. Immobilize the probe

28. Acquire an optimum ultrasound image

29. Verbalize the main components of the optimum ultrasound image

E. Needle guidance and injectate placement

30. Inform the patient of needle insertion

31. Advance block needle adjacent to ultrasound probe

32. Keep needle visible when advancing

33. Reestablish needle visibility during foreword motion

34. Withdraw needle toward skin to reestablish visibility

35. Maintain communication with patient

36. Aspirate before injection of local anesthetics

37. Maintain patient veins during injection

38. Encourage patient to report pain on injection

39. Use test dose of local anesthetics

40. Place full block dose

41. Place sufficient amount of local anesthetics

42. Maintain sterility of procedure field

43. Correct breaches of sterility if required

F. Block clinical assessment

44. Remove cast or splint from the blocked arm

45. Establish presence or absence of pain

46. Assess motor power along distribution of median nerve

47. Assess motor power along distribution of ulnar nerve

48. Assess motor power along distribution of radial nerve proximal fibers

49. Assess motor power along distribution of radial nerve distal fibers

50. Assess motor power along distribution of musculocutaneous nerve

51. Assess sensory function along distribution of median nerve

52. Assess sensory function along distribution of ulnar nerve

53. Assess sensory function along distribution of radial nerve

54. Assess sensory function along distribution of musculocutaneous nerve

Abbreviation: MG, metric group.

Table 2 Abbreviated summary of the definitions of the 32 (noncritical and critical) errors developed during procedure characterization

1. Procedure room (block room) is not prepared for performing the block

2. Not running conversation with the patient

3. No monitoring attached (critical)

4. No intravenous cannula sited (critical)

5. Not administering oxygen (critical)

6. Adopt an awkward posture during block performance

7. Patient dignity not maintained

8. Causing patient pain during positioning

9. Personal apparel not removed

10. Antiseptic solution not dried before needle insertion

11. Failure to maintain asepsis (critical)

12. Incorrect placement of local skin infiltration

13. Advance needle other than infiltrated skin area

14. Advance needle out of plane

15. Veins are compressed during injection

16. Failure to visualize needle

17. Advance needle without tip being visible

18. Continuously move needle to reestablish needle visibility

19. Multiple needle redirections without established visibility

20. Require multiple skin puncture during procedure

21. Failure to ask patient about pain and paresthesia

22. Failure to aspirate before injection

23. Failure to use test dose

24. Place less than sufficient amount of local anesthetic

25. Continue to inject despite incorrect site of injection

26. Failure to place local anesthetic around each nerve

27. Advance needle despite patient reporting pain (critical)

28. Continue to inject despite evidence of intraneural injection (critical)

29. Place block dose without visual evidence of injectate (critical)

30. Continue to inject despite aspirating blood (critical)

31. Place needle into a nerve (critical)

32. Not performing block assessment