6. Mind the Gap

3 year old dies from avoidable air embolus.

Mind the Gap & Why ‘Ruby’s Rule’ Won’t Work

Ruby Yen Chan, a 3 year old from Queensland, died from an air embolus. You can read the coroners report here.

The process of disconnecting an intravenous fluid bag allowed air to enter it. When the bag was later re-connected (re-spiked) the air passed through the intravenous line and into Ruby’s circulation leading to her death.

The coroner’s recommendations focused on outlawing the practice of IV fluid bag re-spiking:

image

While we strongly support ‘Ruby’s Rule’ we recognise it will do little to stop the same adverse event from happening again.

IV fluid bag re-spiking occurs every day in hospitals throughout the world.

This is ‘The Gap’ that exists between work as perceived by managers and work as performed by front line staff.

Many hospital staff haven’t heard of Ruby’s Rule, and even those who have continue to re-spike bags for numerous reasons – understanding these requires an understanding of the complexity of our work environments.

image

This gap is endemic to top down safety approaches.

Fortunately a highly effective solution to this adverse event already exists on the front line.

It’s not the re-spiking that’s the issue – it’s that air enters the IV fluid bag on disconnection. If we can stop air entering the fluid bags then problem solved – this is a forcing function and is a highly effective safety measure:

Hierarchy

IV fluid bags with valves which prevent air entrainment (on right in image below) are already in use in many hospitals.

Click on image for video:

image

Preventing future similar events would require replacement of all non-valved IV fluid bags with valved ones – at no extra cost.

In Australia, the Therapeutic and Goods Administration (TGA) are best placed to effect this. We encourage them to do what’s best for patient safety.

We strongly support increased transparency in our error reporting systems so front line staff can develop effective safeguards. #ShowUsOurErrors

(patientsafe has no financial interest with any products discussed on this website)

14 thoughts on “6. Mind the Gap

  1. Should not be hanging bags of fluid in any child. All fluids should go through a syringe driver as happens in UK. This eliminates accidental air entrainment and syringe driver will not push air through.

    Like

    1. How about in theatres – are syringe drivers always used there? This patient was on an aeroplane retrieval where equipment is limited.
      We can’t guarantee that syringe drivers will always be used.
      The risk of air emboli via this mechanism is not limited to the paediatric population.
      The use of syringe drivers does not contraindicate introducing other safeguards.

      Like

      1. Some transport aircraft may not be large enough to allow syringe drivers or tall enough to allow gravitational IV flow. It’s highly likely the staff member who re-spiked the IV fluid bag wasn’t the person who applied the pressure bag to it. We need to recognise workplace complexity.

        Like

  2. It would be wise to do a cost-benefit analysis of the (hundreds? thousands? tens of thousands? of) hours of nursing time expended prepping new tubing and spiking a new bag every time. Preparing new tubing could also result in an air embolism if the nurse forgets to flush the line. Depending on how frequently that occurs, forcing nurses away from re-spiking bags could have a small safety benefit, or be even less safe.

    Like

  3. I work in intensive care in the UK and our trust has a strict no respike policy, while I can not guarantee this is never done throughout the trust I can be sure it is never done in my department of work for 2 reason the risk of air administration and also it is a high infection control risk, a lot of education and awareness went into stopping this practice and it took some time but it has been the normal to never respike in our trust for a number of years now and it is concerning that this practice still takes place.

    Like

  4. I have worked for three major hospital systems here in the US and all three have very strict no re-spike rules. We use new tubing for every new bag of fluid also. You never reuse bags or tubing.

    Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s