Chen, Ruby Yan
Deceased
Ruby Yan Chen
Demographics
3y, female
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.
Error types
Clinical conditions
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
- 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
- Education and promotion of the prohibition on re-spiking of intravenous fluid bags should occur, potentially termed 'Ruby's Rule' to aid adherence
- Queensland Ambulance Service should implement their new clinical practice guideline regarding the priming of giving sets
- 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
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