Sign In
CPSI Share                                                                      
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Back to Search
Single or Multiple Incident: Multiple
Date: 9/18/2020 12:00:00 AM
Country: South Korea
A patient was prescribed a chest and abdomen computer tomography (CT) following a diagnosis of non-small cell lung cancer. On the day of the examination, a health care worker discovered that about 10cc of air was introduced into the syringe connected to the patient prior to injecting contrast medium. While sitting on the waiting chair after the examination, the patient lost consciousness fell due to cardiac arrest. The patient recovered consciousness after CPR was performed but died the next day in the intensive care unit. The chest and abdomen computed tomography images taken just before the incident suggest a cardiac arrest caused by air embolism. Recommendations and examples of related preventive activities are included to prevent patient safety incidents that cause air ingress into veins due to careless use of automatic contrast media injectors.

Additional Details

Device:
Automatic contrast media injectors
Medication/Gas/Fluid:
Contrast media

Environment / Equipment
  1. - An automatic contrast media injector with air monitoring devices can reduce the risk of air embolism, but it should be used only when the user observes air ingress on a regular basis (no rely on air monitoring devices only).
Rules / Policies / Procedures
  1. - Specific task assignment according to the occupational group and the number of users of the automatic contrast media injector should be managed. - Procedures for the easy use of automatic contrast media injector should be prepared. - Manual and instructions should be checked before using automatic contrast media injector. - It should be double checked if all air is removed from the syringe and the injector's connection tube and the fluid line before connecting automatic contrast media injector to the patient. - Air ingress should be periodically observed during the contrast media injection and stop the procedure in case of air ingress. - Empty syringes used in contrast media injection should be removed after the end of procedure.
Training
  1. - Users of automatic contrast media injectors should be limited to those who have been trained for the proper use of contrast media and the risk of air embolism. - Periodic competency(correct use of contrast media) tests on users of automatic contrast media injector should be performed.

A fatal risk caused by carelessness in the use of an automatic contrast media injector