Medication Error Rate Exceeds Acceptable Threshold During Insulin Administration
Penalty
Summary
A medication error rate of 7.69% was identified during medication administration observations, exceeding the acceptable threshold of less than 5%. Specifically, two medication errors were observed out of 26 opportunities. One incident involved an LPN preparing and administering insulin to a resident with type 2 diabetes mellitus. The LPN failed to prime the insulin pen before injection, contrary to facility policy, and administered 20 units of Lantus insulin instead of the physician-ordered dose of 18 units. The LPN acknowledged not priming the insulin pen prior to administration, stating that pens were only primed when first opened. The facility's insulin administration policy requires priming the pen before each use to ensure proper dosing and avoid injecting air. The errors were brought to the attention of the Director of Nursing, and the relevant policy was reviewed.