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This article originally posted 12 October, 2010 and appeared in  Safety and Error PreventionBG ControlMedical DevicesCMS2Special Edition - Best of 2010Patient ErrorsDiabetes Clinical Mastery Series Issue 176

Insulin Pump Mystery

"One of our pump-using patients reported a sudden increase in blood glucose lasting several days. No ketones were present, but the blood glucose was chronically elevated (300 mg/dl plus). Changing infusion sets didn't fix it. Rotating to a new body part nor did switching to a fresh vial of insulin. We noticed a symbol on their "home screen" denoting that a special feature was running. Upon investigating, we found that they accidentally switched the pump to a secondary basal pattern with the rate set at 0.0 units/hr. Reverting back to their standard basal program and deactivating the extra basal programs led to immediate resolution."

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Bottom Line:

As a pump trainer I know that often times when it comes to how to change pump settings most patients don’t have a clue. This happens because they may go for a very long time on the first settings in their pump and never get a chance to practice. Setting a second basal program happens quite often as the patient sees their clinician and is instructed to change rates but is not sure how to do it and accidently sets up a second bolus. Experience shows that many users feel if they go back to the home screen they can undo whatever they have done. As a way to protect your patients from this, ask them to call the support center of their respective company and let them walk the patient through the changes. -- Dave Joffe, Editor-in-chief

Report Medication Errors to ISMP:

Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.

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Copyright © 2010 Diabetes In Control, Inc.

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This article originally posted 12 October, 2010 and appeared in  Safety and Error PreventionBG ControlMedical DevicesCMS2Special Edition - Best of 2010Patient ErrorsDiabetes Clinical Mastery Series Issue 176

Past five issues: Diabetes Clinical Mastery Series Issue 198 | Issue 738 | Diabetes Clinical Mastery Series Issue 197 | Issue 737 | Diabetes Clinical Mastery Series Issue 196 |

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