Tuesday , November 21 2017
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Medication Safety Alert: Medtronic MiniMed Revel Insulin Pump

From our partners at the Institute for Safe Medication Practices (ISMP): Office staff at an endocrinology practice was asked to see a patient who was having low blood glucose while receiving their insulin using a Medtronic MiniMed Revel portable infusion pump. The pump allows information to be downloaded and it showed that the patient was getting boluses during the night. The patient vehemently denied administering any doses. However, when presented with the data showing that up to 10 units at a time were being administered, it could not be refuted. It was suspected that the patient leaned over onto the pump while sleeping, putting enough pressure on the activation system that a dose was released….

We (ISMP) asked Medtronic about this, and the company told us it has in fact had rare reports of people accidently rolling over onto the pump at night and activating a bolus. A patient would have to activate 2 buttons for the pump to actually deliver a dose, which is why this is a rare occurrence. There is a feature to lock out the keypad so that this doesn’t happen. The patient was shown how to use this and, sure enough, the problem was resolved.

A second patient also had mysteriously low blood glucose levels while using the Revel pump. In this case, it had nothing to do with accidentally activating the bolus system. Instead, this involved the patient entering erroneous information into pump software. The pump has a bolus dosing "wizard" that allows patients to enter their blood glucose and the amount of carbohydrate grams they’ve eaten. By mistake the patient was accidentally entering the measured blood glucose into the carbohydrate field instead of the number of carbohydrates eaten. For example, 220 was entered in the carbohydrate field instead of 60 grams.

The safest way to administer a bolus dose is to use the glucose meter that goes with the pump. This automatically communicates the glucose level information to the pump so the user does not need to manually enter the results. In this case, the patient’s insurance did not cover the test strips for this pump, so the patient was using his own glucose meter and entering the results manually. Also, the pump will warn the patient when an entry is outside the usual range, but the warning can be overridden. In this case, the patient could not see the pump screens clearly because the backlight lighting is quite dim. Medtronic told us there is no way to make the light any brighter. They agreed to pass on the information from this report internally to consider whether any enhancements were needed to improve the device.
 

Diabetes in Control would like to acknowledge the Institute for Safe Medication Practices’ outstanding work in medication safety, including the above excerpt. For more information on this issue as well as other important safety issues, please visit ISMP.org.

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.

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