Air embolism is a rare but potentially lethal adverse event caused by certain medical and surgical procedures. It is considered a preventable event that can cause catastrophic injury, is a serious reportable event and costs related to its treatment are not paid by Medicare and Medicaid. The Pennsylvania Patient Safety Authority, did a 7 year review and found 74 air embolism inijuries. The majority of these air embolism injuries resulted from central venous catheters and access devices. The ubiquitous use of central venous catheters when combined with the high mortality rate associated with air embolus requires that hospitals pay special attention to the processes and procedures for their use.