Description of Event or Problem · 1
FACILITY BIOMED REPORTED AN OVERINFUSION OF INSULIN WITH PATIENT REQUIRING D-50 TO TREAT LOW BLOOD GLUCOSE. NURSE REPORTED SHE HUNG NEW BAG WITH NEW TUBING AND USED "RESTORE" FEATURE TO PROGRAM 4 UNITS/HR. ONE HOUR LATER AT 2215, USER NOTICED BAG WAS EMPTY, AND CONFIRMED WITH ANOTHER NURSE THAT PUMP SHOWED RATE OF 4 ML/HR ON SCREEN. BLOOD GLUCOSE WAS 124 IN THE HOUR PRIOR TO EVENT, DROPPED TO 87 IMMEDIATELY AFTER EVENT, THEN DOWN TO 56. GAVE TWO 25 ML DOSES OF D-50 AND SUBSEQUENT BLOOD GLUCOSE LEVELS ALL INCREASED. INSULIN RESUMED AT 0400 AT 4 ML (4 UNITS) /HR ON A DIFFERENT PUMP WITH NO FURTHER PATIENT SEQUELAE NOTED. LVP MODULE SEQUESTERED, BUT POC UNIT AND TUBING SET NOT SAVED. REPEATED ATTEMPTS MADE TO GATHER FURTHER CLINICAL INFORMATION ABOUT EVENT WERE UNSUCCESSFUL. NO INFORMATION AVAILABLE ABOUT VOLUME OF FLUID OR CONCENTRATION OF INSULIN IN THE BAG. AS THE POC UNIT EVENT LOG WITH DETAILS OF PROGRAMMING WAS UNAVAILABLE, THE LVP EVENT LOG WAS REVIEWED, BUT RATES DO NOT MATCH REPORT OF EVENT: RATE 6 ML/HR AT 1840, DECREASED TO 5 ML/HR AT 2009, 3 ML/HR AT 2022, 5 ML/HR AT 2023, 3 ML/HR THEN IMMEDIATELY 5 ML/HR AT 2223, 3 ML/HR AT 2323. THERE IS NO EVIDENCE IN THE LOG OF ANY RATE OF 4 ML/HR DURING THE REPORTED TIME OF THE EVENT. REQUESTED THAT DEVICE BE SENT IN FOR FUNCTIONAL EVALUATION, BUT BIOMED REPORTED THAT WHEN HE LOOKED FOR IT, HE FOUND IT HAD BEEN PUT BACK INTO CIRCULATION AND HE HAS NO WAY TO FIND IT.