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J Korean Soc Emerg Med > Volume 35(2); 2024 > Article
Journal of The Korean Society of Emergency Medicine 2024;35(2): 197-201.
의료실수 공개하기의 경험: 우연히 발견된 정맥 내 공기 색전증 사례
노현1 , 나상운2 , 어은경1
1순천향대학교 부천병원 응급의학과
2국군대전병원 응급의학과
Disclosing medical error: incidentally recognized case of intravenous air embolism
Hyun Noh1 , Sangun Nah2 , Eun Kyung Eo1
1Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
2Department of Emergency Medicine, The Armed Forces Daejeon Hospital, Daejeon, Korea
Correspondence  Eun Kyung Eo ,Tel: 032-621-5119, Fax: 032-621-5018, Email: eoeunkyung@naver.com,
Received: August 8, 2023; Revised: October 8, 2023   Accepted: October 9, 2023.  Published online: April 30, 2024.
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.
Key words: Medical errors; Disclosure; Emergencies; Air embolism
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