Insulin Administered Despite Order to Hold for Low Blood Glucose
Penalty
Summary
A significant medication error occurred when a licensed practical nurse (LPN) administered insulin to a resident despite a physician's order to hold the dose for blood glucose levels less than 110. The resident, who had diagnoses including chronic kidney disease, heart failure, type 2 diabetes mellitus, and protein calorie malnutrition, had a care plan that included monitoring blood sugar and administering insulin as ordered. On the day of the incident, the LPN checked the resident's blood glucose, which was 93, and proceeded to draw up and administer four units of Novolog insulin, contrary to the order to hold the dose for blood sugar below 110. The error was identified during observation and confirmed through interviews and record review. The LPN followed standard procedures for blood glucose testing and insulin administration but failed to adhere to the specific physician order regarding when to withhold insulin. The facility's policy required staff to review physician orders and follow the eight rights of medication administration, which was not done in this instance, resulting in the resident receiving insulin when it should have been withheld.