Medication Error Rate Exceeds Five Percent Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, when two insulin administration errors were observed out of 25 medication opportunities, resulting in an eight percent error rate. Specifically, a licensed nurse administered insulin to a resident with diabetes mellitus without priming either the insulin lispro or insulin glargine pens, did not verify the insulin orders against the medication administration record at the time of preparation, and did not follow manufacturer instructions for the duration the pen button should be depressed during injection. The nurse kept the insulin pen button pressed for only two seconds for both types of insulin, despite manufacturer instructions specifying five seconds for insulin lispro and ten seconds for insulin glargine to ensure full dose delivery. Interviews revealed that the nurse was unsure of the required duration for keeping the insulin needle in the skin and did not follow the facility's policy, which mandates verification of medication orders and adherence to proper administration technique. The administrative nurse confirmed the expectation that all medication orders be verified with the medication administration record prior to administration. The facility's policy also requires that the medication be administered at the proper time, in the prescribed dose, and by the correct route, with specific instructions for insulin pen use that were not followed in this instance.