Failure to Prime Insulin Pen Results in Medication Errors Above 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with 2 errors identified out of 30 observed opportunities, resulting in a 6.66% error rate. Both errors involved the administration of insulin using a Tresiba FlexTouch pen to a resident with type 2 diabetes mellitus and a history of daily insulin use. During two separate medication passes, LPNs prepared and administered the insulin without priming the needle, contrary to the manufacturer's instructions and facility policy, which require priming to ensure accurate dosing. Interviews with staff revealed a lack of understanding regarding the necessity of priming the insulin pen, with one LPN stating it was unnecessary and the ADON initially supporting this view to avoid wasting insulin. However, upon reviewing the manufacturer's instructions, the ADON acknowledged that priming should occur before administration. The DON also confirmed the expectation that air should be removed from the needle prior to insulin administration. These actions and inactions led to the identified medication errors affecting a resident with moderate cognitive impairment and a diagnosis of diabetes mellitus.