We made two safety recommendations to the Royal College of Anaesthetists (RCoA) as a result of our investigation into administering a wrong site nerve block. 

The investigation looked 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.

Safety recommendations

The investigation report, published in September 2018, recommends that the RCoA establish a specialist working group to evaluate the current practices used to reduce wrong site nerve block incidents. It also recommends that any further work identified by the specialist working group to reduce wrong site block incidents is subject to human factors-based testing and evaluation.


RCoA provided a combined response to both safety recommendations. They said:

“The Royal College of Anaesthetists welcomes the publication of the Healthcare Safety Investigation Branch’s (HSIB’s) report on Wrong Site Anaesthetic Nerve Block and supports the recommendation made that the College establishes a working party to evaluate current practices with a view to achieving standardisation.

“In response, the College and the Association of Anaesthetists, working through the Safe Anaesthesia Liaison Group, will develop a specialist working group with key stakeholders to evaluate current practices with the aim of minimising the incidence of wrong site blocks. The group will also examine the human factors that increase the chances of wrong site block including patient position changes during procedures. The College will then take forward any work recommended by the group and ensure that human factors testing and evaluation form a key element in trialling any new or modified procedures.”

Find out more

Find out more about this investigation, including our safety recommendations in full, on the administering a wrong site nerve block investigation page.

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