Colleagues at the Incident Reporting and Investigation Centre (IRIC) in Scotland, contacted us to share an incident where a patient’s body-worn continuous insulin patch pump device was incorrectly identified by their healthcare team as a glucose sensor, when admitted to hospital with a severe hypoglycaemic event and loss of consciousness. As a result, the pump continued to infuse insulin during treatment therefore prolonging, rather than correcting, the hypoglycaemia.

Insulin pumps can be identified by on-device marking and our review of the National Reporting and Learning System (NRLS) did not indicate this to be a widespread safety issue. However, we used this case to signpost Medical Device Safety Officers, Medication Safety Officers and the National Association of Medical Device Educators and Trainers (NAMDET) networks to guidance available from the Association of British Clinical Diabetologists to raise awareness of the potential for this error. In addition, the Royal College of Emergency Medicine highlighted this issue in a Safety Flash to ensure healthcare staff were aware of the risk. 

Publication reference: PRN01208