Failure to Properly Prime Insulin Pen Results in Medication Error
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to properly prime an insulin pen before administering insulin to a resident. According to the facility's policy and the manufacturer's recommendations, insulin pens must be primed prior to each use by dialing a set number of units, removing the needle cap, and ensuring that at least one drop of insulin appears at the needle tip. During observation, the RN dialed the priming dose but left the needle cap on and held the pen horizontally, pressing the injection button without confirming that insulin appeared at the needle tip. The RN then proceeded to administer the prescribed insulin dose to the resident without verifying proper priming. The resident involved required 2 units of insulin due to a blood glucose level of 218. The RN confirmed during an interview that she was not in-serviced or checked off by the facility on the correct procedure for priming insulin pens and stated she followed the method taught in nursing school. The failure to follow established policy and manufacturer instructions resulted in a significant medication error, as the insulin pen was not properly primed prior to administration.