Medication Error Rate Exceeds 5% Due to Improper Insulin Administration
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as required by both federal and facility policy. During observation of 25 medication administrations, two errors were identified, resulting in an 8% error rate. The errors were specifically related to the administration of insulin for one resident who had physician orders for Lantus and Humalog insulin. The facility's policy and competency forms outlined the correct procedure for insulin pen use, including the requirement to prime the pen before administration. On the observed occasion, an LPN prepared and administered both Lantus and Humalog insulin to the resident without priming either insulin pen, contrary to established procedures. The LPN acknowledged during interview that the pens were not primed prior to administration. This failure to follow proper insulin administration protocol constituted the medication errors that contributed to the facility's elevated medication error rate.