Tandem quality engineer evaluated pump data and concluded the following: lowest blood glucose (bg) entered into the pump by the user during the week prior to (b)(6)2019 was 53 mg/dl on (b)(6)2019 at 1:51 pm.Prior to the low bg, there were no obvious requests or deliveries that would cause bg levels to drop.User requested a 6.16 unit bolus at 9:07 am for 40 grams of carbohydrates and a bg of 202 mg/dl.There were no erratic basal rate adjustments.During the week prior to (b)(6)2019, user made bolus requests while still having insulin on board (iob) and the cartridge change sequence was completed several times.Making bolus requests while still having iob could lead to a low bg event.If user did not disconnect during the ¿fill tubing¿ step of the cartridge change sequence, insulin would be delivered, and this could cause bg levels to drop.There is no evidence that the pump experienced a malfunction or failure.
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