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Insulin Pump Safety Measure

Dec 3, 2012

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


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