Ruby Yan Chen, a 3 year old from Queensland, died from an avoidable air embolus (see here).
The process of disconnecting a valveless 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. You can read the full report (see here).
While we agree the process of IV fluid bag re-spiking should be prohibited we recognise this practice persists throughout the world.
A solution to this problem which focuses solely on preventing fluid re-spiking will not work.
We do however have an effective solution to this issue – please help us promote it further.
Valved IV Fluid Bags, which don’t entrain air, are already used in many institutions without problem.
Cost is not an issue here – the valved, safer 1L Hartmanns bags from Fresenius Kabi are $1.09 in NSW while the valveless bags from Baxter are $1.10.
We will save 1c per bag while providing patients with a safer environment.
We have informed both the Therapeutic And Good Administration (TGA) and the Australian Commission on Safety and Quality in Health Care (ACSQHC).
If you know of any institution using valveless IV fluid bags (the majority at present) please present this issue to senior hospital managers.
IV fluid bag re-spiking occurs every day in hospitals throughout the world.
This demonstrates ‘The Gap’ that exists between work as perceived by managers and work as performed by front line staff. This gap is endemic to top down safety approaches.
Many hospital staff haven’t heard of Ruby’s Rule (the name given to a rule dictating not to re-spike intravenous fluid bags) 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.
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:
IV fluid bags with valves which prevent air entrainment (on right in image below) are already in use in many hospitals – they’re actually 1c cheaper too.
(Please note air in the top of bag on left). Click on image for video:
Preventing future similar events would require replacement of all non-valved IV fluid bags with valved ones – at a potential cost saving of 1c per bag.
Perhaps you could also help. Please consider sending an email directly to Baxter the manufacturer of the ‘valveless’ intravenous fluid bags at: USAT_Pharmacovigilance@Baxter.com
You might want to cut and paste this message or write one of your own:
Given the risk of intravenous air embolism would you consider redesigning your intravenous fluid bags to include a valve to prevent air entrainment. Thank you.
(PatientSafe has no financial interest with any products discussed on this website).
In NSW Fresenius Kabi product code Compound Sodium Lactate 1L is K694531 box of 10 $10.90.
Dr Helen Rowlands
SEPTEMBER 16, 2016 AT 9:48 AM EDIT
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.
SEPTEMBER 16, 2016 AT 10:56 AM EDIT
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.
SEPTEMBER 17, 2016 AT 3:35 AM EDIT
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.
SEPTEMBER 20, 2016 AT 4:39 AM EDIT
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.
SEPTEMBER 18, 2016 AT 1:17 AM EDIT
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.
SEPTEMBER 19, 2016 AT 8:56 AM EDIT
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.