Significant Medication Error: Insulin Overdose Due to Improper Administration
Penalty
Summary
A deficiency occurred when a resident with diabetes, who was prescribed Toujeo (a long-acting insulin) at a dose of 36 units daily via a pre-filled pen, was administered an incorrect dose. On the day of the incident, the assigned nurse was unable to locate the appropriate pen needles in the medication cart and, without seeking additional supplies or assistance, used a standard 100 unit/mL insulin syringe to draw up and inject 36 units from the Toujeo pen. This resulted in the resident receiving three times the prescribed dose, as Toujeo is concentrated at 300 units/mL, unlike standard insulin preparations. The error was discovered after the resident's blood sugar was found to be significantly low (52 mg/dL) during a routine check, and the resident subsequently developed symptoms of hypoglycemia, including pallor, sweating, cool and clammy skin, and malaise. The nurse had not verified the insulin concentration or the proper administration method as required by facility policy, and did not realize the risk of overdose when using a syringe with a different calibration than the pen device. The facility's policies clearly stated that insulin should be administered according to the physician's order and manufacturer instructions, which prohibit withdrawing Toujeo from the pen with a syringe due to the risk of overdose. The resident required treatment for hypoglycemia, including oral glucose, intravenous dextrose, and increased monitoring until blood sugar levels stabilized. Interviews confirmed that the nurse was familiar with the resident and the medication, but failed to follow proper procedures for insulin administration and did not check for available supplies elsewhere in the facility. The Director of Nursing confirmed that additional pen needles were available in the supply room at the time of the incident.