Description of Event or Problem · 1
ON 10/28/2010, DIABETES EDUCATOR REPORTED PT WAS ADMITTED TO HOSPITAL ON (B)(6) 2010 FOR SEVERE DIABETIC KETOACIDOSIS (DKA). BLOOD GLUCOSE WAS 1612 MG/DL WHEN SHE ARRIVED TO HOSPITAL, AND PT WAS PLACED IN INTENSIVE CARE UNIT. DIABETES EDUCATOR STATED SHE MUST HAVE BEEN IN DKA FOR SEVERAL DAYS. INSULIN CARTRIDGE HAD BEEN REMOVED BY TIME OF CALL, AND THERE WAS AN AIR BUBBLE IN IT. IT WAS UNK IF THE AIR BUBBLE WAS THERE DURING EVENT. FIANCÉ' PROVIDED ADDITIONAL INFO. PT STARTED TO NOT FEEL WELL ON (B)(6) 2010 AND STARTED TO VOMIT ON (B)(6) 2010. BLOOD GLUCOSE ELEVATED TO "HI" MG/DL BY (B)(6) 2010. PT CALLED PHYSICIAN AND WAS PRESCRIBED ANTIBIOTIC AND MEDICATION FOR VOMITING. ON (B)(6) 2010, PT WAS NOT COHERENT, WEAK, AND COULD NOT WALK. AMBULANCE WAS CALLED AND PT WAS TRANSPORTED TO HOSPITAL. PT WAS TAKEN OFF INFUSION DEVICE AND HOOKED UP TO IV'S. BLOOD GLUCOSE AT TIME OF CALL WAS 180 MG/DL, AND PT WAS STARTING TO FEEL BETTER. PHYSICIAN "FELT STRONGLY" THE INFUSION DEVICE HAD MALFUNCTIONED. INFUSION DEVICE, INSULIN CARTRIDGE, AND INFUSION SET WERE REPLACED AND REQUESTED FOR EVALUATION. FOLLOW-UP WAS COMPLETED WITH PT ON (B)(6) 2010. PT WAS DIAGNOSED WITH A VIRAL INFECTION AND DID NOT BELIEVE INFUSION DEVICE WAS CAUSE OF DKA. TARGET BLOOD GLUCOSE IS BELOW 150 MG/DL. PT USED BACKUP INFUSION DEVICE FOR 4 MONTHS PRIOR TO EVENT. SHE ORIGINALLY STARTED BACKUP INFUSION DEVICE DUE TO UNEXPLAINED HYPERGLYCEMIA ON PRIMARY INFUSION DEVICE. PT SWITCHED TO PRIMARY INFUSION DEVICE ON (B)(6) 2010. PT REPORTED BASAL RATES SHOULD HAVE BEEN ADJUSTED ON PRIMARY INFUSION DEVICE, BUT SHE WAS NOT FEELING WELL. THERE WERE NO LEAKS OF INSULIN AND INFUSION SITE WAS NOT DISLODGED. PT DID NOT NOTICE AIR BUBBLE IN CARTRIDGE. NO LIFESTYLE CHANGES WERE REPORTED. INFUSION DEVICE WAS NOT DROPPED OR CRACKED, AND IT WAS NOT EXPOSED TO WATER OR OTHER LIQUIDS. PT RECEIVED REPLACEMENT INFUSION DEVICE AND BLOOD GLUCOSE WAS WITHIN TARGET RANGE AT TIME OF FOLLOW-UP.