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Diabetes Disaster Averted #35: Infusion Set Risks

May 27, 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.  However, I noticed a problem when he went to the cannula fill amount: 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 and/or changed, but the error and “overfilling/overdosing” of insulin could have been going on for some time.

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.

Lessoned Learned:

When working with a patient using an insulin pump, you have to remember that this is a new technology for the patient and requires more follow ups.

When working with pump patients, always check the cannula fill amount, especially when switching to a new type of infusion set.

Denise West, RN, BSN, CDE




Copyright © 2011 Diabetes In Control, Inc.


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