Significant Medication Error: Insulin Overdose Due to Syringe Mix-Up
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and multiple diagnoses, including insulin-dependent diabetes mellitus, was administered an incorrect dose of insulin. The physician's order specified that the resident should receive 8 units of insulin for a blood sugar reading between 351-400 mg/dl. On the date of the incident, the resident's blood sugar was 377 mg/dl, but the registered nurse administered 80 units of insulin instead of the prescribed 8 units. This error was due to the nurse using a tuberculin syringe rather than an insulin syringe, as insulin syringes were not available at the time. Following the administration of the incorrect insulin dose, the resident exhibited symptoms such as diaphoresis, cool skin, rapid breathing, and changes in level of consciousness. The resident was subsequently transferred to an acute care hospital and admitted to the Intensive Care Unit for management of hypoglycemia and hypotension resulting from the insulin overdose. Staff interviews and documentation confirmed the medication error and the use of the wrong syringe type, which directly led to the resident's hospitalization.