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My insulin pump controller has a bug

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Re: My insulin pump controller has a bug

#102
post #85
post #2

Non-twitter link: https://nitter.net/morganherlocker/status/173045572181552742... (edit: I'm not the author) "Notified today that my insulin pump controller has a bug where the leading decimal point will be dropped, ie: changing a dose of .21 units to 21 units. I can reproduce randomly ~1 in 5 times so probably a race condition. Easily one of the worst software bugs I have ever heard of."

It sounds like the bug was in the Android app. Shouldn't the microcontroller (on the pump) be validating dose values received? (dose > MAX_DOSE) ? return DOSE_TOO_HIGH : return DOSE_ACCEPTED; 20 units is obviously dangerous for a single dose.

My same thought, Max Dose in an hour setting should prevent severe hypoglycemia as a fail safe, but I did not see anything mentioned in the article about that on Insulet website. My son has this model but we use controller that comes with it, not the Android app, which is where the issue is. Closed loop OmniPod 5/Dexcomm is a game changer for Type 1 management. As a software developer I worry about this sort of thing but hopefully max dose fail safe gets this.

Re: My insulin pump controller has a bug

#103
post #37
post #28

Earlier quoted context omitted.

But does the device contain that much insulin?

This device can hold up to 200 units of insulin in it's cartridge. I'm not familiar with it to say if it has any safety interlocks to administer some sort of max dose lower than that at a time though.

There is a user setting for maximum bolus. For me I have it set to 30, but some may set it lower. Indeed that might be recommended after this.

Re: My insulin pump controller has a bug

#104

Cue the "you wouldn't steal a car" music. ♫ "You wouldn't demand open-source software for life-critical contexts instead of the industry-perfected closed software" ♫

Are you implying that open source software doesn't have bugs because there are thousands of reviewers looking at every commit?

If you do you haven't actually worked on open source software.

Even in critical software people just LGTM.

Re: My insulin pump controller has a bug

#105
post #33

A clearer description of the bug is here: https://twitter.com/Tims_Pants/status/1730515134731182490 It's wild that this sort of bug got through testing. As a diabetic it feels like our insulin pump software is very conservative and lacking in features especially compared to what some of the "closed loop" things would like to do. That seems reasonable if the manufacturers are having to do lots of safety testing. But i…

for these critical applications which require reliable oprations as lives are at stack. formal verfication will help by reducing bugs more than traditional testing. they are not bullet proof but still better. z notation is one of many.

Re: My insulin pump controller has a bug

#106

Earlier quoted context omitted.

Why do so many people / companies insist on using grossly euphemistic managerspeak like this?

liability

An insulin pump is probably a class II medical device. The manufacturer is already liable.

Re: My insulin pump controller has a bug

#108

This is the Omnipod 5 when using the Android app as the controller. I received the email this morning. This is indeed a pretty terrible bug. I'm hopeful the confirmation screen prevented any real harm from being done. E: I can reproduce. It seems to happen around 1 in 10 entries for me.

>I'm hopeful the confirmation screen prevented any real harm from being done. I hope so too, but I doubt it. Confirmation screens are notorious for becoming habituated and then ignored. Yes, even important ones. https://alistapart.com/article/neveruseawarning/

Yep, when you use something a few times a day it's very easy to get interface blindness. I use a t.slim myself and catching something like .10 and 10 is going to be very, very easy to miss. Probably need a leading zero like 0.10 to make it stand out. And even then most the time I'm clicking the conformations to get on with my life and do something else.

Re: My insulin pump controller has a bug

#109
post #78
post #36

Earlier quoted context omitted.

Why? Safety Critical Software engineers are expensive. If you write a webstack with Node.js and React to run the insulin pump you can hire web developers. They are much cheaper. And who would be able to tell the difference? Boomer lawyers and judges working on the lawsuit targeted against us won't understand.

Judges have the benefit of experts spoon feeding them information, and no deadlines other than the ones they impose on themselves. The judge I worked for wrote the panel decision throwing out the Communications Decency Act, at age 64. In addition to covering packet routing and caching, it did a pretty good job of capturing the decentralized ethos of the Internet: https://archive.nytimes.com/www.nytimes.com/library/cy…

That's the opposite of the conventional wisdom on the strengths of the judiciary, so much so that there's a norm that courts defer to legislatures on findings of fact, since they're so comparatively hamstrung at generating facts.

Re: My insulin pump controller has a bug

#110
post #85

Earlier quoted context omitted.

It sounds like the bug was in the Android app. Shouldn't the microcontroller (on the pump) be validating dose values received? (dose > MAX_DOSE) ? return DOSE_TOO_HIGH : return DOSE_ACCEPTED; 20 units is obviously dangerous for a single dose.

Absolutely. The App should be considered hostile by the pump firmware until proven otherwise.

This is quite the overreaction. There is both a confirmation screen and a maximum bolus setting to ameliorate the issue until an OTA update can be provided.

Stranding users who use the app without access to our lifesaving medical device is... Bold, to say the least.

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