Significant Medication Errors Due to Improper Administration and Omission
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration practices. One resident with severe cognitive impairment and a diagnosis of type 2 diabetes mellitus was prescribed insulin Lispro via sliding scale and insulin Glargine daily. During observed administration, a registered nurse failed to prime the insulin pens before injection, a step required to ensure needle patency and accurate dosing. The nurse admitted to never having been educated on priming insulin pens, and the facility did not provide a policy or procedure for insulin pen administration. Another resident, with no cognitive impairment and a history of traumatic brain injury, aphasia, and bipolar disorder, was prescribed Levetiracetam for seizure prevention. The resident's bedtime medication was omitted by an LPN, who later acknowledged simply missing the administration. The omission was discovered the following morning when the medication was found still in the medication pack. The facility's policy required medications to be administered as ordered and within prescribed time frames, but this was not followed in this instance. Both incidents were confirmed through review of medical records, staff interviews, and direct observation. The facility's policies outlined the correct procedures for medication administration, including the seven rights of medication administration, but these were not adhered to in the cases described, resulting in significant medication errors for the two residents.