Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
A review of the medical record, observation, and staff interview revealed that a resident with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease was not free from significant medication errors. The resident, who had intact cognition and required staff assistance with activities of daily living, had physician's orders for Humalog insulin 22 units subcutaneously before meals and Glargine insulin 54 units subcutaneously in the morning. On the observed date, an LPN administered both Humalog and Glargine insulin to the resident without priming the insulin pens prior to administration. The LPN confirmed during interview that she did not perform the priming step. Manufacturer's guidelines for both types of insulin specify that priming the pen is necessary before each injection to ensure proper dosing and function, but this step was omitted during the medication administration.