Because 15% of air embolism cases are asymptomatic and nearly all are sudden, standardized, universal prevention procedures are essential to reduce the occurrence (McCarthy et al., 2017). The prevention techniques are already available in most hospitals, and therefore require little additional investment, but require prioritization and bundling to ensure consistency in delivery of air embolism prophylaxis.

Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.

Actionable steps include:

• Executive Summary Checklist
• Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
• Performance improvement plan to follow if improvements are necessary
• Clinical workflow for preoccupation with workflow for areas of improvement
• How to educate patients and family members about the significance of their role throughout the continuum
• Guidance on how to measure outcomes