Insulin Overdose Due to Medication Administration Error
Penalty
Summary
A medication administration error occurred when a nurse administered 40 units of Humalog insulin to a resident with type 2 diabetes, heart failure, and hypertension, instead of the physician-ordered 14 units before breakfast. The resident's blood sugar was recorded as 322 prior to the administration, and the nurse reported reviewing and verifying the physician's orders before giving the insulin. However, the nurse inadvertently drew up and administered the incorrect dose, realizing the mistake only after the injection was nearly complete. The nurse attributed the error to feeling flustered due to earlier difficulties with computer access and a fire alarm during the shift. The resident was cognitively intact, independent with activities of daily living, and had a care plan in place for diabetes management, including blood glucose monitoring and insulin administration as ordered. The facility's documentation and interviews confirmed that the five rights of medication administration were not followed, specifically the right dose, resulting in the resident receiving an excess of 26 units of insulin. The incident was identified and reported by the nurse, and the supervisor and family were notified.