Failure to Administer Correct Insulin Resulting in Significant Medication Error
Penalty
Summary
A medication administration error occurred when an LPN administered 10 units of Humalog insulin to a resident instead of the prescribed 10 units of Lantus insulin at bedtime. The LPN obtained the insulin from the emergency kit after noticing the resident was out of Lantus, but failed to verify the medication against the resident's Medication Administration Record (MAR) and did not check the insulin pen to ensure it was the correct drug. This action was not in accordance with the facility's policy, which requires verification of medication orders and the medication itself at multiple points prior to administration. The resident involved had a diagnosis of Type II Diabetes Mellitus and was cognitively intact, with orders for regular blood glucose monitoring and specific insulin regimens: Lantus at bedtime and Novolog three times daily. On the day of the incident, the resident's blood sugar readings were within normal limits prior to the error. After the incorrect administration of Humalog, the LPN discovered the error several hours later while reviewing paperwork, prompting immediate assessment of the resident's blood sugar, which was found to be critically low. The LPN did not follow the established rights of medication administration, specifically failing to confirm the correct medication and dosage before administration. The error was self-identified by the LPN, who then notified the appropriate clinical staff and initiated measures to address the resident's hypoglycemia. The incident was documented in the facility's records, and interviews confirmed that the LPN did not adhere to the required medication administration procedures, leading to the significant medication error.