Significant Medication Error: Wrong Insulin Administered
Penalty
Summary
A significant medication error occurred when a resident with a history of myocardial infarction, chronic kidney disease, and type 2 diabetes mellitus was administered the wrong type and dose of insulin. The resident was prescribed Lantus insulin, 95 units at bedtime, and Humalog insulin, 15 units with meals, to be held if blood sugar was below 150. On the evening in question, a licensed practical nurse mistakenly administered 60 units of Humalog instead of the ordered 95 units of Lantus. This error was identified and reported by the nurse, and the resident was monitored for signs and symptoms of hypoglycemia, though none were observed at the time. The incident was confirmed through interviews with facility staff, the resident's representative, and the medical director, as well as a review of the resident's medical record and facility policies. The facility's policy required that medication errors be prevented and reported. Following the error, the resident's physician was notified and ordered the resident to be transferred to the hospital for evaluation and monitoring, where multiple glucose tests were performed. The deficiency was identified during a complaint investigation and was substantiated by documentation and staff interviews.