New Technology, New Errors: How to Prime an Upgrade of an Insulin Infusion Pump

$20.00 plus tax (Refund Policy)

Buy Article:

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.

Document Type: Research Article

Publication date: March 1, 2007

More about this publication?
  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
  • Editorial Board
  • Information for Authors
  • Subscribe to this Title
  • Information for Advertisers
  • Reprints and Permissions
  • Index
  • ingentaconnect is not responsible for the content or availability of external websites
Related content

Tools

Favourites

Share Content

Access Key

Free Content
Free content
New Content
New content
Open Access Content
Open access content
Subscribed Content
Subscribed content
Free Trial Content
Free trial content
Cookie Policy
X
Cookie Policy
ingentaconnect website makes use of cookies so as to keep track of data that you have filled in. I am Happy with this Find out more