Significant Medication Error: Incorrect Insulin Administered
Penalty
Summary
A significant medication error occurred when a diabetic resident, who was prescribed both rapid-acting and long-acting insulin, was administered the incorrect type of insulin. The resident was ordered to receive Humalog (rapid-acting insulin) with meals and insulin glargine (long-acting insulin) at bedtime. On the evening in question, the resident was given 54 units of Humalog instead of the prescribed insulin glargine at bedtime by an LPN. Following the administration of the incorrect insulin, the resident experienced symptoms including headache, upset stomach, and a low blood sugar reading. The physician was notified of the resident's condition and ordered an emergency department transfer for evaluation and treatment. The resident was diagnosed with hypoglycemia in the emergency department and received intravenous dextrose before returning to the facility. The facility's investigation confirmed that the LPN administered the wrong insulin, and the error was documented in both the medical record and the facility's transfer form. The LPN acknowledged the mistake during an interview, and it was noted that the resident's blood sugar level at the time was 75 mg/dL, although this was not documented in the medical record. The facility's medication administration policy requires medications to be administered by authorized and trained personnel in accordance with laws and accepted standards of practice.