Significant Medication Error Due to Incorrect Insulin Order Transcription
Penalty
Summary
A significant medication error occurred when a resident with type 2 diabetes was admitted with a hospital discharge order for insulin glargine 5 units at bedtime. However, the facility admission order was incorrectly transcribed by an LPN as 70 units at bedtime, a substantial deviation from the original order. This error was not identified during the chart check or morning meeting, and the incorrect dose was subsequently administered by another LPN, who questioned the amount but proceeded as per the written order. Following the administration of the incorrect insulin dose, the resident was initially alert and cooperative, but later was found unresponsive with low blood pressure, decreased oxygen saturation, and a blood glucose of 58. Emergency services were called, and the resident was transferred to the hospital, where intubation was required due to non-responsiveness. The facility's policy required two nurses to review admission orders for accuracy, but this double-check process was not completed prior to the incident.