Home / Therapies / Devices / A Common Error with Insulin Pumps

A Common Error with Insulin Pumps

Mar 16, 2021
 

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. The problem was noted when he went to the cannula fill amount — I noticed the default fill amount came up as over five units when the actual fill amount needed was only 0.3 units for his 6 mm infusion set. It was unclear when the fill amount might have been entered or changed, but the error and “overfilling/overdosing” of insulin could have been going on for some time.

Lesson Learned:

 

When working with pump patients, always check the cannula fill amount. 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 vary and should be changed in their insulin pump.

Denise West, RN, BSN, CDE

If you have a “Diabetes Disaster Averted” story, please let us know! If we feature your Disaster Averted in our Diabetes Clinical Mastery Series e-newsletter, you will receive a $25 gift card. Please click here to submit a short summary of the incident, what you feel you learned from handling the incident, and your name and title. If you prefer to remain anonymous, please let us know, but still give us your name and address (so we can send you the gift card).

 

 

 

 

 

Copyright © 2011, 2021 HIPER LLC

 

 

See more stories about diabetes Disasters Averted.