Medication Administration Errors with Insulin Pen-Injectors
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 12%. During an observation, a surveyor noted that three errors occurred out of 25 opportunities, involving two residents and one nurse. The errors were related to the improper administration of insulin using pen-injectors. The nurse did not follow the manufacturer's specifications for priming the pen-injector and holding it in place for the required time, which could affect the insulin dosage. For Resident #46, the nurse primed the insulin pen-injector incorrectly by holding it in a slanted downward position instead of upright, as required by the manufacturer's instructions. The nurse also failed to hold the pen-injector in place for the recommended five seconds after injection, potentially leading to an inaccurate dose. The resident had a physician's order for insulin lispro to be administered according to a sliding scale based on blood sugar results. Similarly, for Resident #38, the nurse repeated the same errors with both insulin lispro and insulin glargine pen-injectors. The nurse did not hold the pen-injectors upright during priming and removed them from the skin too quickly after injection. The resident had orders for both types of insulin, with specific dosages to be administered based on blood sugar levels and at scheduled times. These deficiencies were acknowledged by the facility's Interim Director of Nursing and Regional Clinical Nurse, who confirmed the importance of following the manufacturer's instructions for insulin administration.
Plan Of Correction
1. Corrective Action of Areas Affected: Facility cannot retroactively fix the procedure for administration for resident #38 and #46. RN#1 has been re-inserviced on the process for administration. 2. Other Areas Affected: All residents receiving insulin have the potential to be affected by this deficient practice. 3. Systemic Changes to Prevent Future Occurrences: Licensed nursing staff have been re-educated on medication administration policies and procedures, including insulin administration. The Director of Nursing/designee has completed medication administration competencies for licensed nursing staff related to insulin administration. 4. Monitoring of Corrective Action: The Director of Nursing/designee will randomly monitor licensed nursing staff for proper priming of insulin pens and administration of insulin to residents weekly x4 weeks, then monthly x2. Results of the audit will be reported monthly to the Quality Assurance Improvement Plan Committee.