Significant Medication Error: Insulin Administered to Wrong Resident
Penalty
Summary
A significant medication error occurred when a nurse administered 2 units of Humalog insulin to a resident who did not have a prescription for insulin and was not diagnosed with diabetes. The nurse checked the resident's blood glucose level, found it to be 195, and proceeded to give the insulin, which was actually prescribed for another resident. The error was identified and documented in a medication incident report, which confirmed that the nurse had failed to properly identify the resident before administering the medication. The resident involved had a history of hypertension, hyperlipidemia, major depressive disorder, dysphagia, left shoulder pain, and macular degeneration, and was noted to be cognitively impaired. According to the Minimum Data Set, the resident did not receive insulin as part of their regular care. Interviews with the resident's representative, the DON, and other staff confirmed that the resident did not have an insulin order and had no history of diabetes. The nurse responsible for the error was not available for interview, but it was confirmed by multiple sources that the nurse had administered the medication to the wrong resident. The incident was reported to the medical provider, the resident's representative, and the DON. The resident's blood glucose levels were monitored following the error, and no adverse effects or negative outcomes were observed. The facility's pharmacy consultant and medical director were also notified and confirmed that no harm resulted from the error. The nurse involved in the incident was no longer employed at the facility following the event.