Sufficient air can enter blood vessels rapidly, over 1 or 2 seconds, causing a cardiac arrest or cerebral air embolus which often leads to death.

The magnitude of this problem is not well known – adverse event being dispersed in place and time.  Also the usual healthcare safety approach of education, alerts and policy writing doesn’t appear to have impacted on preventing this issue. In fact reports demonstrate the frequency of this adverse event is only increasing (see here).

We discuss how a human factors approach may significantly help in reducing adverse event frequency (see here).

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