Significant Medication Error in Insulin Administration
Penalty
Summary
A deficiency occurred when a nurse failed to accurately prepare and administer insulin according to a physician's sliding scale order for a resident with Type 2 Diabetes Mellitus and Diabetic Neuropathic Arthropathy. The nurse was observed withdrawing 5 units of regular insulin from a multi-dose vial, despite the resident's blood glucose reading requiring only 2 units as per the sliding scale. The nurse initially stated she had drawn up 2 units, but upon review by another nurse, it was confirmed that 5 units had been prepared. The facility's policy requires that medications be administered as prescribed, with the individual administering the medication verifying the correct dosage, resident, medication, time, and route. The Director of Nursing confirmed that preparing 5 units when only 2 units were ordered was not acceptable practice. This medication error was identified through observation, interview, and record review, and had the potential to affect all residents in the facility who receive medications.