Medication Error Rate Exceeds Five Percent Due to Improper Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and regulation. During observation of 38 medication administration opportunities for five residents, two errors were identified, resulting in a medication error rate of 5.26 percent. Specifically, an LPN administered insulin to a resident using two different insulin pens but did not prime the needles prior to administration and did not hold the pen against the abdomen for ten seconds after injection, as required to ensure full delivery of the medication. The LPN was observed cleaning the injection sites and administering the correct dosages but omitted these critical steps in the insulin pen protocol. Interviews with the LPN, DON, and ADON revealed a lack of awareness regarding the need to prime insulin pen needles and to hold the pen in place for ten seconds post-injection. The facility's policy on medication administration, including insulin pump management, was reviewed, but both the LPN and nursing leadership confirmed they were unaware of these specific requirements for insulin pen use. This lack of knowledge and adherence to proper insulin administration technique directly contributed to the medication errors observed.