Evaluation of the Pediatric Regional Anesthesia Time-Out Checklist
A Simulation Study
Pediatric Anesthesia
Submitted August 2025 by Dr Su May Koh
Read by 3 Journal Watch subscribers
This simulation-based study examined the effect of a Paediatric Regional Anaesthesia Time-out Checklist training for pediatric anaesthetists and trainees. Not surprisingly it found that checklist training and having a shared-mental model led to an increased number of safety items performed before a simulated anesthetic block scenario.
The Society for Paediatric Anesthesia Quality and Safety Committee developed a 14 item Paediatric Regional Anesthesia Time-Out Checklist and in the process of evaluating and testing the checklist designed a study to observe the behaviours of 11 attending anesthesiologists and resident dyads in 132 simulated scenarios.
There were 12 scenarios developed of which in 4 scenarios, medical staff were expected to decline performing the block due to a safety concern (programmed error) in the scenario (eg coagulation issues or excessive local anesthetic doses). The scenarios were designed to encompass types of errors previously reported in the literature making them more relevant. Medical staff in pairs (attending/consultant anesthesiologist with resident/trainee) completed 6 medium fidelity simulation scenarios (two of which had a programmed error). This was followed by completion of a survey and then checklist training. After the training, the pairs completed 6 further medium fidelity simulation scenarios (again with two scenarios having a programmed error). This was followed by a debrief and survey completion.
Each scenario was expected to last 2-4 minutes and each attending and trainee were given different stem cards and expected to communicate. No specific instructions were given about who should initiate the checklist time-out and the scenario ended when the block needle was inserted. Video recordings of the scenarios were performed and scored for safety items achieved and whether the decision to perform the block or abort the block was recorded.
Results
132 simulated scenarios were performed by 22 anesthesiologists. In terms of the study’s primary outcome, they found that a greater number of safety items were completed after training on the Pediatric Regional Anesthesia Time-Out Checklist for each of the 11 pairs (p=0.002). Of note 78% of safety items studied were performed after training and 41% of safety items were performed prior to training. The authors also found that the team’s choice to perform or abort the regional anesthetic occurred (as expected) more often after the Checklist training (p=0.001). Of note prior to checklist training in 3 scenarios, teams chose to perform the regional anesthetic block despite a programmed error (safety concern). Two of the scenarios involved a patient with a low platelet count having a neuraxial block where before checklist training the medical staff elected to proceed with the block. Interestingly after the checklist training no teams chose to perform the blocks in scenarios where there were safety concerns/programmed errors.
The checklists were overall favourably rated for usability and design and participants thought favourably of checklists in the medical setting.
Commentary
This study is interesting as it examines checklist testing using pairs of anesthesiologists namely an attending and a trainee, promoting additional team interaction and a shared mental model. The authors commented that the number of times that each pairing had worked together previously varied thus potentially showing the utility of the checklist even for teams of variable interpersonal familiarity. A possible limitation includes the learning effect in a simulated environment with a relatively small sample size. The authors also commented that this was a single site study in a centre with a high safety culture and where checklists were widely accepted, this may not be true of all paediatric centres.
Take-Home Messages
Even though serious adverse events are rare in pediatric regional anesthesia, potential complications such as wrong-sided blocks, local anesthetic dosing errors may be prevented by the use of checklists and clear communication. A block time-out with a checklist is now an expected and important part of ensuring patient safety. This may be particularly true in pediatric anesthesia where the majority of our blocks are performed in anesthetised patients.
