Medication Transcription and Administration Error Resulting in Insulin Overdose
Penalty
Summary
A resident with a history of heart failure, diabetes, and hypertension was admitted to the facility with hospital discharge orders specifying the use of Humalog insulin via an insulin pump, with a maximum daily dose of 100 units. The nursing admission evaluation failed to document the presence of the insulin pump, and the resident's care plan did not address the management of the device. The admitting nurse transcribed the hospital discharge order incorrectly, recording Humulin R to be administered subcutaneously instead of the prescribed Humalog via insulin pump. This transcription error was not clarified with the physician, and the order was not written clearly by the admitting nurse. As a result of these documentation and transcription errors, the resident was administered 90 units of subcutaneous Humulin R, rather than the intended insulin via pump. This led to an insulin overdose and hypoglycemia, requiring the resident to be sent to the emergency department for monitoring and treatment. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the errors in the admission evaluation, order transcription, and medication administration, which resulted in actual harm to the resident.