Coronial
QLDother

Chen, Ruby Yan

Deceased

Ruby Yan Chen

Demographics

3y, female

Coroner

O'Connell

Date of death

2012-08-09

Finding date

2014-12-12

Cause of death

massive air embolism

AI-generated summary

Ruby Chen, 3 years old, died from massive air embolism during aeromedical transfer from Blackwater to Rockhampton Hospital. The fatal sequence occurred when a paramedic re-spiked a partially-used IV saline bag (containing ~115 mL) with a new giving set, allowing air to enter the bag. The bag was placed in an opaque pressure cuff that forced both fluid and air through the IV line into the patient's circulation. At 250 mL/hour infusion rate, fluid exhausted after ~24 minutes, sending ~70-100 mL of air directly into her bloodstream. Clinical lesson: never re-spike IV bags; ensure single-use spike labeling; prohibit opaque pressure cuffs in aeromedical settings; use infusion pumps when feasible. The constellation of factors—re-spiking, priming with new set, opaque pressure bag, helicopter environment—was unusual and not previously encountered in practice, but entirely preventable.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

retrieval medicineemergency medicinepaediatricsintensive care

Error types

proceduralsystem

Clinical conditions

air embolismfebrile illnessinfluenza Adehydration

Procedures

intravenous fluid administrationre-spiking of IV bagpriming of giving setaeromedical retrieval

Contributing factors

  • re-spiking of partially-used IV saline fluid bag
  • air entering IV bag during re-spiking procedure
  • use of opaque pressure cuff forcing air into circulation
  • priming of new giving set introducing air into bag
  • limited fluid volume remaining in reused bag (~115 mL)
  • helicopter environment with low light and confined space
  • infusion rate of 250 mL/hour exhausting remaining fluid
  • use of pressure cuff instead of infusion pump

Coroner's recommendations

  1. IV saline bags should be marked in contrasting coloured lettering (e.g., yellow on black or red on clear) with 'SINGLE SPIKE ONLY' terminology adjacent to the injection port
  2. Education and promotion of the prohibition on re-spiking of intravenous fluid bags should occur, potentially termed 'Ruby's Rule' to aid adherence
  3. Queensland Ambulance Service should implement their new clinical practice guideline regarding the priming of giving sets
  4. Aeromedical retrieval services should investigate whether elimination of opaque pressure cuffs is feasible and practical, with preference for infusion pumps with alarm systems and safeguards; decision-making timeframe of six months
Full text
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