Patient safety and quality improvement: Iatrogenic venous air embolism in diagnostic imaging

The Medicines and Healthcare products Regulatory Agency (MHRA), the executive agency for the Department of Health (DoH) in England, ensures medicines and medical devices work and are safe. An incidence of fatal arterial embolism (AE) was reported, in which air was inadvertently injected into a patient rather than contrast media during a Computer Tomography (CT) examination with a contrast power injector pump. Instigating the issuing of safety notification MDA_SN_96261 however this was withdrawn with the implication being that the equipment is safe and the incidence was human error.