New technology, new errors

How to prime an upgrade of an insulin infusion pump

Ann M. Rule, Andjela Drincic, Kimberly A. Galt

Research output: Contribution to journalArticle

9 Citations (Scopus)

Abstract

Background: A series of use errors occurred when switching an ambulatory care clinic patient from an older model to a newer model of an ambulatory continuous subcutaneous insulin infusion pump. Case Report: The nurse practitioner (N.P.) reviewed the new pump's mechanics with the patient, who had a 26-year history of Type 1 diabetes mellitus, and supervised the patient's programming of the pump. At bedtime, a blood sugar of > 250 mg/dL prompted the patient to give herself insulin via the pump. The next morning, she was treated at the emergency department for diabetic ketoacidosis. Case Analysis: The pump had been improperly primed, resulting in no insulin delivery. The incident also reflected the absence of a fail-safe mechanism(s) on the pump to alert the user to the improper priming and inappropriate handoff of the patient's care. Unlike the old pump, the new pump did not require manual priming. The lack of delivery of insulin resulted in DKA, a potentially life-threatening complication of diabetes. A root cause analysis suggested several important safety issues, including skipping of steps on the patient training checklist and other shortcuts in patient training. Discussion: The clinic developed policies and procedures, including mandatory formal training for each pump model by the certified pump trainer and for initiation of insulin pump therapy. This case illustrates the importance of a structured device selection process, provider education, patient education, and monitoring for safety and effectiveness of technological devices in care.

Original languageEnglish
Pages (from-to)155-162
Number of pages8
JournalJoint Commission Journal on Quality and Patient Safety
Volume33
Issue number3
StatePublished - Mar 2007
Externally publishedYes

Fingerprint

Infusion Pumps
Insulin
Technology
Patient Education
Root Cause Analysis
Safety
Subcutaneous Infusions
Equipment and Supplies
Diabetic Ketoacidosis
Nurse Practitioners
Physiologic Monitoring
Diabetes Complications
Ambulatory Care
Mechanics
Checklist
Type 1 Diabetes Mellitus
Blood Glucose
Hospital Emergency Service
Patient Care

All Science Journal Classification (ASJC) codes

  • Leadership and Management

Cite this

New technology, new errors : How to prime an upgrade of an insulin infusion pump. / Rule, Ann M.; Drincic, Andjela; Galt, Kimberly A.

In: Joint Commission Journal on Quality and Patient Safety, Vol. 33, No. 3, 03.2007, p. 155-162.

Research output: Contribution to journalArticle

@article{a85e3213edd24c879b468e140efd1e8c,
title = "New technology, new errors: How to prime an upgrade of an insulin infusion pump",
abstract = "Background: A series of use errors occurred when switching an ambulatory care clinic patient from an older model to a newer model of an ambulatory continuous subcutaneous insulin infusion pump. Case Report: The nurse practitioner (N.P.) reviewed the new pump's mechanics with the patient, who had a 26-year history of Type 1 diabetes mellitus, and supervised the patient's programming of the pump. At bedtime, a blood sugar of > 250 mg/dL prompted the patient to give herself insulin via the pump. The next morning, she was treated at the emergency department for diabetic ketoacidosis. Case Analysis: The pump had been improperly primed, resulting in no insulin delivery. The incident also reflected the absence of a fail-safe mechanism(s) on the pump to alert the user to the improper priming and inappropriate handoff of the patient's care. Unlike the old pump, the new pump did not require manual priming. The lack of delivery of insulin resulted in DKA, a potentially life-threatening complication of diabetes. A root cause analysis suggested several important safety issues, including skipping of steps on the patient training checklist and other shortcuts in patient training. Discussion: The clinic developed policies and procedures, including mandatory formal training for each pump model by the certified pump trainer and for initiation of insulin pump therapy. This case illustrates the importance of a structured device selection process, provider education, patient education, and monitoring for safety and effectiveness of technological devices in care.",
author = "Rule, {Ann M.} and Andjela Drincic and Galt, {Kimberly A.}",
year = "2007",
month = "3",
language = "English",
volume = "33",
pages = "155--162",
journal = "Joint Commission Journal on Quality and Patient Safety",
issn = "1553-7250",
publisher = "Joint Commission Resources, Inc.",
number = "3",

}

TY - JOUR

T1 - New technology, new errors

T2 - How to prime an upgrade of an insulin infusion pump

AU - Rule, Ann M.

AU - Drincic, Andjela

AU - Galt, Kimberly A.

PY - 2007/3

Y1 - 2007/3

N2 - Background: A series of use errors occurred when switching an ambulatory care clinic patient from an older model to a newer model of an ambulatory continuous subcutaneous insulin infusion pump. Case Report: The nurse practitioner (N.P.) reviewed the new pump's mechanics with the patient, who had a 26-year history of Type 1 diabetes mellitus, and supervised the patient's programming of the pump. At bedtime, a blood sugar of > 250 mg/dL prompted the patient to give herself insulin via the pump. The next morning, she was treated at the emergency department for diabetic ketoacidosis. Case Analysis: The pump had been improperly primed, resulting in no insulin delivery. The incident also reflected the absence of a fail-safe mechanism(s) on the pump to alert the user to the improper priming and inappropriate handoff of the patient's care. Unlike the old pump, the new pump did not require manual priming. The lack of delivery of insulin resulted in DKA, a potentially life-threatening complication of diabetes. A root cause analysis suggested several important safety issues, including skipping of steps on the patient training checklist and other shortcuts in patient training. Discussion: The clinic developed policies and procedures, including mandatory formal training for each pump model by the certified pump trainer and for initiation of insulin pump therapy. This case illustrates the importance of a structured device selection process, provider education, patient education, and monitoring for safety and effectiveness of technological devices in care.

AB - Background: A series of use errors occurred when switching an ambulatory care clinic patient from an older model to a newer model of an ambulatory continuous subcutaneous insulin infusion pump. Case Report: The nurse practitioner (N.P.) reviewed the new pump's mechanics with the patient, who had a 26-year history of Type 1 diabetes mellitus, and supervised the patient's programming of the pump. At bedtime, a blood sugar of > 250 mg/dL prompted the patient to give herself insulin via the pump. The next morning, she was treated at the emergency department for diabetic ketoacidosis. Case Analysis: The pump had been improperly primed, resulting in no insulin delivery. The incident also reflected the absence of a fail-safe mechanism(s) on the pump to alert the user to the improper priming and inappropriate handoff of the patient's care. Unlike the old pump, the new pump did not require manual priming. The lack of delivery of insulin resulted in DKA, a potentially life-threatening complication of diabetes. A root cause analysis suggested several important safety issues, including skipping of steps on the patient training checklist and other shortcuts in patient training. Discussion: The clinic developed policies and procedures, including mandatory formal training for each pump model by the certified pump trainer and for initiation of insulin pump therapy. This case illustrates the importance of a structured device selection process, provider education, patient education, and monitoring for safety and effectiveness of technological devices in care.

UR - http://www.scopus.com/inward/record.url?scp=33947314308&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=33947314308&partnerID=8YFLogxK

M3 - Article

VL - 33

SP - 155

EP - 162

JO - Joint Commission Journal on Quality and Patient Safety

JF - Joint Commission Journal on Quality and Patient Safety

SN - 1553-7250

IS - 3

ER -