Best Practice| Volume 36, ISSUE 4, P359-366, August 2021

Perioperative Peripheral Nerve Block Safety Education: A Quality Improvement Project

  • Author Footnotes
    1 At the time of this work, the author was a doctor of nurse anesthesia practice student at Midwestern University, Glendale, AZ.
    Pauline Zelaya
    Address correspondence to Pauline Zelaya, 8009 Macnish Dr, NE, Albuquerque, NM 87109.
    1 At the time of this work, the author was a doctor of nurse anesthesia practice student at Midwestern University, Glendale, AZ.
    Department of Anesthesiology, Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, NM
    Search for articles by this author
  • Author Footnotes
    1 At the time of this work, the author was a doctor of nurse anesthesia practice student at Midwestern University, Glendale, AZ.



      The purpose of the quality improvement (QI) project was to improve patient safety by increasing the consistency of monitor application and oxygen administration during the placement of peripheral nerve blocks (PNBs), advance the knowledge of perianesthesia staff about PNB safety, and develop a PNB hospital policy.


      QI project using the focus, analyze, develop, and execute model.


      The project had two parts, an educational component that was deployed in the three hospitals (hospital A, hospital B, hospital C) and an observation component that was conducted in only one of the hospitals (hospital A). Baseline observation of monitor and oxygen application was recorded at hospital A for 3 months. Assessment of perioperative personnel's baseline knowledge regarding PNB safety was attained using a knowledge assessment tool in the three hospitals. Learners in the three hospitals were given a pretest and post-test to measure the change in knowledge level after a PNB safety presentation was given. Monitor and oxygen application during nerve block placements were observed and recorded after the PNB safety presentation at hospital A. Statistical analysis was completed to determine if significant differences in knowledge levels in the three hospitals and monitor and oxygen application at hospital A existed after an educational intervention was delivered to the perioperative teams.


      Participants' knowledge level increased 13% overall with post-test scores greater than 90% after the educational intervention. Monitor application and administration of oxygen during PNB placement improved from 2% to 100% in a preliminary 3-week postintervention review. Systematic changes were implemented to facilitate adherence to best practice measures.


      PNB safety presentations significantly improved staff's knowledge regarding PNB procedures and potential problems. A multidisciplinary team approach was used to facilitate changes to improve electrocardiogram, blood pressure, pulse oximetry, and oxygen use in this patient population. A proposed PNB policy was accepted as a protocol. Patients are safer with increased monitoring.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of PeriAnesthesia Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cozowicz C.
        • Poeran J.
        • Memtsoudis S.G.
        Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery.
        Br J Anaesth. 2015; 115: ii57-ii67
        • Cozowicz C.
        • Poeran J.
        • Zubizarreta N.
        • Mazumdar M.
        • Memtsoudis S.G.
        Trends in the use of regional anesthesia: neuraxial and peripheral nerve blocks.
        Reg Anesth Pain Med. 2016; 41: 43-49
        • Health Industry Distributors Association
        2018 Ambulatory Surgery Center Market Report.
        (Available at:)
        Date accessed: July 22, 2020
      1. Total knee arthroplasty (TKA) removal from the Medicare inpatient-only (IPO) list and application of the 2-midnight rule. Centers for Medicare & Medicaid Services. Released January 24, 2019. Outreach and publications. Available at: Accessed July 22, 2020.

        • Joshi G.
        • Gandhi K.
        • Shah N.
        • Gadsden J.
        • Corman S.L.
        Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities.
        J Clin Anesth. 2016; 35: 524-529
        • Bowling T.
        • Knauft W.
        • Shah N.
        • Sinha S.
        Making the most of ultra-sound guided regional anesthesia.
        Anesthesiology News. 2019; 16
        • Jeng C.
        • Rosenblatt M.
        Overview of peripheral nerve blocks. In: Post TW, ed. UpToDate. Waltham, MA.
        (Available at:)
        • Warren L.
        • Pak A.
        Local Anesthetic Systemic Toxicity. In: Post TW, ed. UpToDate. Waltham, MA.
        (Available at:)
        • Neal J.M.
        • Barrington M.J.
        • Fettiplace M.R.
        • et al.
        The third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on local anesthetic systemic toxicity: executive summary 2017.
        Reg Anesth Pain Med. 2018; 43: 113-123
        • Barrington M.J.
        • Kluger R.
        Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade.
        Reg Anesth Pain Med. 2013; 38: 289-297
        • El-Boghdadly K.
        • Pawa A.
        • Chin K.J.
        Local anesthetic systemic toxicity: current perspectives.
        Local Reg Anesth. 2018; 11: 35-44
        • Dickerson D.M.
        • Afelbaum J.L.
        Local anesthetic systemic toxicity.
        Aesthet Surg J. 2014; 34: 1111-1119
      2. Stanford Anesthesia Cognitive Aid Group∗. Emergency Manual: Cognitive aids for perioperative critical events. See for latest version. Creative Commons BY-NC-ND. 2016 (Version 3.1) ∗Core contributors in random order: Howard SK, Chu LF, Goldhaber-Fiebert SN, Gaba DM, Harrison TK. Accessed July 24, 2020.

        • Bhatia A.
        • Lai J.
        • Chan V.W.
        • Brull R.
        Case report: pneumothorax as a complication of the ultrasound-guided supraclavicular approach for brachial plexus block.
        Anesth Analg. 2010; 111: 817-819
        • Kakazu C.
        • Tokhner V.
        • Li J.
        • Ou R.
        • Simmons E.
        In the new era of ultrasound guidance: is pneumothorax from supraclavicular block a rare complication of the past?.
        Br J Anaesth. 2014; 113: 190-191
        • Gauss A.
        • Tugtekin I.
        • Georgieff M.
        • Dinse-Lambracht A.
        • Keipke D.
        • Gorsewski G.
        Incidence of clinically symptomatic pneumothorax in ultrasound-guided infraclavicular and supraclavicular brachial plexus block.
        Anaesthesia. 2014; 69: 327-336
        • Imran J.B.
        • Eastman A.L.
        JAMA. 2017; 318: 974
        • Bourdon L.
        Care of the patient receiving local anesthesia.
        AORN J. 2015; 101: 10-12
        • American Association of Nurse Anesthetists
        Standards for nurse anesthesia practice. 2019.
        (Available at:)
      3. Belgian standards for patient safety in anesthesia. Revision 2019 of the last version published in the Acta Anaesthesiologica Belgica, 2002, 53 (1): 5-9.
        Acta Anaesthesiol Belg. 2020; 71: 5-14
        • Fencl J.L.
        Guideline implementation: local anesthesia.
        AORN J. 2015; 101: 682-692
        • Ferguson W.
        • Coogle C.
        • Leppert J.
        • Odom-Maryon T.
        Local anesthetic systemic toxicity (LAST): Designing and educational effort for nurses that will last.
        J Perianesth Nurs. 2019; 34: 180-187
        • Sermeus L.
        • Pirson A.
        • Breebaart B.
        • et al.
        Clinical guidelines for the practice of peripheral nerve blocks in the adult.
        Acta Anaesthesiol Bel. 2013; 64: 105-108
        • Gadsen J.
        • McCally C.
        • Hadzik A.
        Monitoring during peripheral nerve blockade.
        Curr Opin Anaesthesiol. 2010; 23: 656-661
        • Association of Perioperative Registered Nurses
        AORN eGueidlines+. Guidelines for perioperative practice: local anesthesia.
        (Available at:)
        • American Society of Perianesthesia Nurses
        ASPAN's Clinical Practice Committee “FAQ” page.
        (Available at:)
      4. American Society of Anesthesiologists Standards for Basic Intra-Operative Monitoring. Anesth Patient Saf Found.
        (Available at:)