Description of Event or Problem · 1
ON (B)(6) 2010, PATIENT REPORTED ELEVATED BLOOD GLUCOSE OVER THE PREVIOUS 36 HOURS. BLOOD GLUCOSE ELEVATED TO "HI" AND WAS ABOVE 600 MG/DL. PATIENT CHANGED THE INFUSION SET AND INSULIN CARTRIDGE AND BOLUSED 6 UNITS OF INSULIN. BLOOD GLUCOSE REMAINED ELEVATED. PATIENT THEN GAVE AN INSULIN INJECTION, AND THIS LOWERED BLOOD GLUCOSE TO 196 MG/DL. PATIENT CHECKED BLOOD GLUCOSE A FEW HOURS LATER AND IT HAD ELEVATED TO 379 MG/DL. PATIENT BELIEVED THE INSULIN DELIVERY OF THE INFUSION DEVICE WAS TOO LOW. NO ERROR MESSAGES WERE RECEIVED ON INFUSION DEVICE. ADAPTER, INFUSION SET, INSULIN CARTRIDGE, AND BATTERY WERE USED PER SPECIFICATION. INFUSION DEVICE WAS NOT DROPPED OR EXPOSED TO WATER. TIME, DATE, AND BASAL RATES WERE PROGRAMMED CORRECTLY. PATIENT DID NOT FORGET TO BOLUS. THERE WAS NO BLOOD OR LEAKING INSULIN IN THE SYSTEM. PATIENT DID NOT HAVE SCAR TISSUE OR BRUISING AT SITE LOCATION OR CHANGES TO HEALTH, MEDICATION, STRESS, OR EXERCISE. INFUSION DEVICE AND ADAPTER WERE REPLACED AND REQUESTED FOR EVALUATION. INSULIN CARTRIDGE AND INFUSION SET WERE DISCARDED. THE PATIENT DID NOT REQUIRE TREATMENT FROM A HEALTH CARE PROFESSIONAL OR SECOND PARTY TO ADDRESS THE ISSUE. FOLLOW-UP WAS COMPLETED ON (B)(6) 2010. PATIENT REPORTED BLOOD GLUCOSE RETURNED TO NORMAL RANGE OF 130 MG/DL AFTER REPLACEMENT.