Diffuse Bi-hemispheric Cortical Infarction Secondary to Cerebral Air Embolism After Elective Esophagogastroduodenoscopy: A Case Report and Review of Literature

Systematic Risk Analysis and Mitigation Strategies for Near-Miss Events in Interventional Operating Room Nursing

Purpose

The aim of this study is to examine the characteristics of intraoperative nursing near-miss events in interventional operating rooms, systematically identify and analyze associated risks, and propose effective mitigation strategies.

Patients and Methods

A retrospective study was conducted using a specially designed survey focused on nursing near-miss events in Interventional operating rooms. Records of intraoperative near-miss events voluntarily reported by medical and nursing staff between January 2023 and March 2024 were analyzed. Grey relational analysis was used to evaluate and identify the associated risk factors.

Results

A total of 81 near-miss events were reported, with the majority (50%) occurring after 8 PM. These events were categorized into 6 main types: medication errors (60.49%), issues with consumables (16.05%), tubing-related incidents (8.64%), specimen handling errors (7.4%), transfer handover issues (4.93%), and patient transport problems (2.46%). Grey relational analysis identified air embolism formation during pressurized fluid administration as the highest risk event (ξ1 = 0.369). The risk factors were ranked as follows: weak coordination ability and lack of responsibility among nurses > operational interruptions > inadequate professional capability > poor communication between medical staff and nurses > equipment malfunction > frequent emergency surgeries and a fast paced working environment.

Conclusion

Medication administration errors are frequently encountered, with air embolisms during pressurized fluid infusion representing the most significant risk. Operational interruptions are major contributors to these errors, often influenced by the coordination skills and professional competencies of nurses. Clinically, it is crucial to enhance the identification and management of near-miss events to reduce the incidence of adverse outcomes during surgical procedures.

Venous air emboli during esophagoscopy confirmed by computed tomographic pulmonary angiography -a case report

BACKGROUND

Esophagogastroduodenoscopy (EGD) is vital for the diagnosis and treatment of various gastrointestinal conditions but carries a low risk of venous air embolism (VAE). We report a case of VAE during EGD, confirmed by computed tomographic pulmonary angiography (CTPA).

CASE

A 56-year-old male with a history of hypopharyngeal cancer underwent EGD for dysphagia-related esophageal dilation. Signs of VAE were noted, prompting swift interventions, including oxygen therapy, positional changes, and CTPA. CTPA revealed the Mercedes-Benz sign, pneumomediastinum, and a minimal pneumothorax. The patient's oxygen saturation improved within 30 min before undergoing CTPA, and he was discharged on postoperative day 4.

CONCLUSIONS

Timely recognition of VAE, resulting in appropriate interventions supported by CTPA, resulted in favorable patient outcomes.