Description of Event or Problem · 0
IT WAS REPORTED THAT THE USER ATTEMPTED TO ANNOUNCE A MEAL AND RECEIVED AN ¿UNABLE TO PROCEED, PLEASE CHECK BACK IN 5 MINUTES¿ MESSAGE, AFTER WHICH TUBING FLOW WAS CONFIRMED, THE CANNULA WAS FILLED, INSULIN DELIVERY WAS RESUMED, AND DATA WERE SYNCED, REVEALING TWO PRIOR MEAL ANNOUNCEMENTS WITHIN ABOUT TWENTY MINUTES AND APPROXIMATELY 8 UNITS OF INSULIN ON BOARD. SYMPTOMS INCLUDED RISK FOR HYPOGLYCEMIA GIVEN CUMULATIVE INSULIN DOSING, WITH THE USER ADVISED TO CONSUME ADDITIONAL FOOD; THE BLOOD GLUCOSE AT THE END OF THE CALL WAS 183 MG/DL. OUTCOMES INCLUDED USER EDUCATION ON INSULIN ON BOARD AND MEAL ANNOUNCEMENT TIMING, WITH RECOMMENDATION TO INGEST A MORE SUBSTANTIAL CARBOHYDRATE SOURCE TO MITIGATE POTENTIAL RAPID GLUCOSE DECLINE. INVESTIGATION INCLUDED REVIEW OF DEVICE DATA, VERIFICATION OF INFUSION SET FUNCTION, CONFIRMATION OF RESUMED INSULIN DELIVERY, AND ASSESSMENT OF RECENT MEAL ENTRIES AND INSULIN ON BOARD. INVESTIGATION OF THIS CASE REVEALED MULTIPLE MEAL ANNOUNCEMENTS OVER A SHORT INTERVAL LEADING TO HIGHER THAN TYPICAL INSULIN ON BOARD, WHILE THE INFUSION SET AND DELIVERY PATHWAY APPEARED FUNCTIONAL AND INSULIN DELIVERY WAS CONFIRMED. IT WAS CONCLUDED, BASED ON PREVIOUSLY ESTABLISHED FINDINGS FOR SIMILAR REPORTS, THAT USER INTERACTION RESULTING IN DUPLICATE MEAL ANNOUNCEMENTS AND CUMULATIVE INSULIN DOSING WAS THE LIKELY CAUSE.