Tuesday , November 21 2017
Home / For Your Practice / Safety / Insulin Pump Safety Measure

Insulin Pump Safety Measure

I was working with a patient who’d recently had a pump upgrade and although he said he didn’t have any issues with infusion set changes, I urged him to change his set while I was present.

He did very well with filling his reservoir and inserting his infusion set but when he went to the cannula fill amount I noticed that 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 overfilling and thus 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.

Lesson Learned: When working with pump patients, always check the cannula fill amount.

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.

Report_Now

*****

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 © 2012 Diabetes In Control, Inc.

 

←Previous Diabetes Disaster Averted 
Inspecting Injection Areas

Next Diabetes Disaster Averted 
Longtime Insulin Users Can Still Make Mistakes

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