60-year-old coming to OR after redo sternotomy (AVR and ascending aorta aneurysm). Multiple infusions on pumps in addition to insulin infusion via pump (not syringe). Bedside nursing wanted to consolidate and took insulin off pump (patient was euglycemic). The nurse was concerned the clamp and roller had not been closed; she called the OR warning that insulin might have free-flowed. First blood glucose was 23; glucose infusion required for 4 hours. Reeducation of staff occurred.

“You know, I always thought a fail-safe system was supposed to be somewhat safe... from failure.”

— Jack O'Neill, Stargate SG-1 (T.V. series from 1997-2007)

For many years, medications were given via a roller clamp where the clinician “counted drops” to set the dose. Low-volume infusion pumps (LVP) replaced gravity drips in the 1970s, but they still relied on gravity (Biomed Instrum Technol 2016;50:253-62). Evolution of “smart pumps” accelerated in the 1990s...

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