Disclosing medical error: incidentally recognized case of intravenous air embolism

ABSTRACT

A peripheral intravenous catheter was inserted to administer analgesics to a patient who visited the emergency department with numbness in her arm and neck pain after a motor vehicle accident. A cervical spine computed tomography was performed for diagnosis, and an air embolism was accidentally discovered in the internal jugular vein. The medical staff believed that the embolism was caused by intravenous catheterization and administration. As a result, a “medical error disclosure” and the “sorry works” approach were conducted on the patient. The authors wish to discuss this experience.