Home / Resources / Disasters Averted / Diabetes Disaster Averted #35: Infusion Set Risks

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

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.



And if you have a “Diabetes Disaster Averted” story, please also send it in separately to Diabetes In Control. If we use it you will receive a Visa Gift Card worth $50.00. Click here to let us know the details. (You can use your name or remain anonymous if you prefer.) Please note that ISMP is not associated with this Gift Card promotion.

Copyright © 2011 Diabetes In Control, Inc.


←Previous Diabetes Disaster Averted 
Changing Medication Formulation

Next Diabetes Disaster Averted 
Mixing Insulins

For the complete list of Diabetes Disasters Averted, just follow this link.