“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.”
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:
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