The Human Factors of Continuous Subcutaneous Insulin Infusion: Modeling Insulin Pump Use Issues

Abstract

Continuous subcutaneous insulin infusion (CSII) devices are commonly used in the treatment of patients with diabetes mellitus. These devices release basal doses of insulin and can be used to deliver boluses of insulin when needed. Use errors involving CSII devices may have serious consequences: an overdose of insulin can result in hypoglycemia and even death, while too little insulin may result in diabetic ketoacidosis and coma. A targeted search of the database of adverse events in the Veterans Health Administration yielded information about patient safety incidents involving CSII devices, including the location and type of error. A model of CSII therapy that includes relevant characteristics of the user, use environment, and task was developed and used to explore potential error modes. By examining adverse events associated with CSII device use and by considering other potential error modes, it may be possible to redesign devices, treatment plans, hospital policy and procedures to minimize the risk of patient harm.