Published February 3, 2026
A woman came to the emergency room with stomach pain, trouble going to the bathroom, and extreme sleepiness. The pharmacist talked to her and her spouse and reviewed the list of medicines she was taking. The pharmacist noted that she was on several medicines, including insulin given through an external pump. Because she was too sleepy to safely use the insulin pump herself, the doctor who admitted her wrote an order to discontinue use of the insulin pump.
On the second day in the hospital, the woman’s blood sugar (glucose) dropped to a very low level. Even after giving her intravenous glucose as ordered, she still was hard to arouse. The nurse notified the doctor. To treat the woman’s pain, she had been given an oral dose of oxycodone (a powerful opioid pain medicine) about 13 hours earlier. So, the doctor ordered a dose of naloxone, a medicine that reverses an opioid overdose, which made her wake up and become alert. At this point, the nurse found out the woman had a pain pump inside her body. This pump contained fentanyl (a strong pain medicine) and bupivacaine (a numbing medicine). The pump was set to give the woman a continuous low dose of medicine to treat her chronic pain. But she was also able to give herself extra doses up to 5 times a day, every 2 hours. The woman’s husband had been giving her these extra doses using a Bluetooth device, but the hospital staff did not know about this.
When the woman was admitted, her husband told the hospital staff that she used a "pain stimulator," but did not say she had a pump inside her body. The healthcare providers thought they meant a TENS (transcutaneous electrical nerve stimulation) machine, which is a small device used outside the body that sends weak electrical signals to nerves to help with pain. No one asked more questions to make sure this was the type of device the woman was using.
Here's what you can do: It is important for hospital staff to get a complete list of all medicines and devices a patient uses when they are admitted. This list needs to include every kind of medicine the patient takes, such as prescription and over-the-counter medicines, injections and infusions, drops and ointments, inhalers, patches, and medicine from pumps that are both inside and outside the body. Try to use the correct terminology when providing information about the medicine and/or devices used. If you are not sure what a device is called, describe it to your healthcare provider and tell them which provider prescribed it for you so they can help investigate. In addition, it is important to let your healthcare provider know if you are allergic to any medicines and what type of reaction you have from that medicine.
To help provide your healthcare provider with the best medication history possible, consider the following recommendations:
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