Medication Error Rate Exceeds 5% Due to Insulin Pen Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, resulting in a calculated error rate of 5.56% based on two errors out of 36 observed opportunities. This deficiency was identified during a review of medication administration for a resident with type two diabetes mellitus, who had physician orders for multiple types of insulin, including Basaglar Kwikpen and Admelog (Insulin Lispro) with sliding scale coverage. During a medication pass, an LPN administered the prescribed doses of insulin but did not prime the insulin pens prior to injection. The LPN confirmed in an interview that she did not prime the Basaglar Kwikpen and Admelog pens, stating she believed priming was unnecessary. The Director of Nursing clarified that the expectation was for nurses to prime insulin pens before administration. Facility policy referenced following manufacturer guidelines, which explicitly require priming the pens before each use. Observations, interviews, and review of manufacturer instructions and clinical guidance all supported the finding that the pens should have been primed, and failure to do so constituted a medication administration error.