NHS England: Correct identification of insulin patch pumps on patients (24 July 2024)

Summary

This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

Content

The Incident Reporting and Investigation Centre (IRIC) in Scotland contacted NHS England 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 NHS England's review of the National Reporting and Learning System (NRLS) did not indicate this to be a widespread safety issue. However, they 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.