Failure to Prime Insulin Pens Results in Medication Errors
Penalty
Summary
The facility failed to properly administer insulin using a Kwik pen for two residents, resulting in a medication error rate of 8%. For both residents, staff did not prime the insulin pen prior to administration as required. Specifically, a registered nurse administered 2 units of Lispro insulin to one resident and 8 units to another without priming the pen, which is necessary to remove air from the needle and cartridge and ensure accurate dosing. The medication administration records confirmed sliding scale insulin orders for both residents. Staff interviews revealed that the nurse responsible did not prime the insulin pen due to nervousness, despite being aware of the correct procedure. Other staff and the co-director of nursing confirmed that priming with at least 2 units is the expected practice, and the manufacturer’s instructions also require priming before each injection. The facility had a census of 158 residents at the time of the survey.