Diabetes Disaster Averted #24: A Common Error with Insulin Pumps

Mar 11, 2011

I was working with a patient who’d recently had a pump upgrade and although he said he didn’t have problems or issues with infusion set changes, I urged him to change his set while I was present. In the process, he did very well with filling his reservoir and inserting his infusion set. The problem was….

noted when he went to the cannula fill amount — I noticed the default fill amount came up as over 5 units when the actual fill amount needed was only 0.3 units for his 6 mm infusion set. It was unclear as to when the fill amount might have been entered or changed but the error and “overfilling/overdosing” of insulin could have been going on for some time.

Lesson Learned:

When working with pump patients, always check the cannula fill amount. I also find that patients who have changed infusion sets may still be using the fill amount from their previous type of set. Depending on the new infusion set, the fill amount may change and should be changed in their insulin pump as well.

Denise West, RN, BSN, CDE

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