Insulin Administered Contrary to Physician Order Due to Nurse Distraction
Penalty
Summary
A deficiency occurred when a nurse administered 2 units of fast-acting sliding scale insulin to a resident with a blood sugar level of 103, despite a physician's order specifying that no insulin should be given for blood sugar levels below 150. The resident, who was nonverbal and unable to assess cognition, had a diagnosis of diabetes and was receiving insulin therapy. The nurse became distracted by multiple nurse aides while at the medication cart, which led to the administration of insulin in error. The nurse initially documented 0 units administered but later confirmed that 2 units had been given. The error was discovered when the resident's family questioned the need for insulin, prompting the nurse to realize the mistake. The nurse reported the incident to the Director of Nursing the same day. The Medical Director confirmed that the physician's orders for sliding scale insulin were not followed, and the Director of Nursing acknowledged that the nurse should not have administered insulin for a blood sugar reading less than 150. The resident did not experience any negative outcome from the medication error.