Medication Error Rate Exceeds Threshold Due to Improper Insulin Administration
Penalty
Summary
A medication error rate of 6.45% was identified during a review of medication administration practices, exceeding the acceptable threshold of less than 5%. The deficiency involved two of thirty-one medications not being administered as ordered. Specifically, a resident with severe cognitive impairment and a diagnosis of type 2 diabetes mellitus had physician orders for insulin Lispro per sliding scale and insulin Glargine daily. Observation revealed that the registered nurse (RN) did not prime the insulin pens before administration, as required by facility protocol and the physician's orders. During the observed medication pass, the RN prepared and administered both insulin Lispro and insulin Glargine without priming the pens, and later confirmed in an interview that she had never been instructed to prime the insulin pen needles. The Director of Nursing (DON) stated that the facility's expectation was for 2 units to be primed after cleansing the septum and attaching the needle for each insulin pen. This failure to follow proper insulin administration technique resulted in the identified medication errors.