Significant Medication Error: Insulin Overdose Due to Misinterpretation of Physician Order
Penalty
Summary
A significant medication error occurred when a resident with a history of heart failure, diabetes, and hypertension, who was moderately cognitively impaired, was administered insulin incorrectly. The resident was admitted with orders for insulin to be administered via an insulin pump, with a maximum daily dose specified. However, the nursing admission evaluation did not document the presence of the insulin pump, and the physician's order for insulin was transcribed by an LPN. Subsequently, another LPN misinterpreted the order and administered 90 units of Humulin insulin subcutaneously in a single dose, rather than using the insulin pump as intended. This error was discovered after the resident became groggy, prompting further investigation and transfer to the emergency room, where the resident was diagnosed with hypoglycemia and accidental insulin overdose. Staff interviews and record reviews confirmed that the medication was not administered as ordered by the physician, resulting in actual harm to the resident. The facility failed to ensure adherence to the six rights of medication administration and did not follow its own policy requiring medications to be given as ordered and in accordance with professional standards.