Significant Medication Error: Incorrect Insulin Dose Administered
Penalty
Summary
A significant medication error occurred when a resident with type II diabetes mellitus, who was assessed as severely cognitively impaired, was administered an incorrect dose of insulin. The physician's orders specified that the resident should receive 15 units of insulin glargine at bedtime and a sliding scale dose of insulin lispro before meals and at bedtime, with 4 units indicated for a blood sugar reading of 185. However, the resident was mistakenly given 15 units of insulin lispro instead of the prescribed 4 units. The error was identified shortly after administration when the LPN realized the mistake upon returning to the medication cart. The incident was reported immediately to the night supervisor, and the responsible party and medical provider were contacted. The resident was monitored for adverse effects, but no negative outcomes were observed during the monitoring period. The deficiency was attributed to the failure to follow the physician's orders during insulin administration.