Medication Error Rate Exceeds Federal Threshold Due to Improper Insulin Administration
Penalty
Summary
During a medication administration observation, a registered nurse administered Lantus Insulin and Novolog Insulin to a resident but failed to follow the manufacturer-recommended technique for insulin pen injections. Specifically, the nurse did not hold the insulin pen in place for the required 5 to 10 seconds after injection, instead withdrawing the needle after only 2 to 3 seconds. This incorrect technique was observed for both types of insulin administered to the resident. Each instance of improper administration was counted as a separate medication error, resulting in a medication error rate of 8%, which exceeds the federal threshold of 5%. The nurse acknowledged the error during a follow-up interview, stating she forgot the correct technique.