Failure to Prime Insulin Pens Results in Medication Error Rate Above Threshold
Penalty
Summary
A medication error rate of 5.56% was identified during a medication pass observation, with two errors out of 36 opportunities involving two residents. During the observed medication administration, a licensed nurse prepared insulin lispro pens for both residents but failed to prime the pens before dialing the prescribed dose. The nurse removed the cap, attached the needle, and dialed the dose directly, omitting the priming step required to ensure accurate dosing. Upon interview, the nurse confirmed not priming the insulin pens and was unaware that priming was a necessary step. The Director of Nursing stated that staff were expected to prime insulin pens with 2 units before dialing the dose. Manufacturer instructions for the insulin lispro pen specify that priming is essential before each injection to ensure correct dosing. The facility's policy also requires medications to be administered safely and as prescribed.