Medication Error Rate Exceeds Threshold Due to Improper Timing of Diabetes Medications
Penalty
Summary
A medication error rate of 8% was identified during a medication pass observation, exceeding the acceptable threshold of less than 5%. Specifically, a licensed vocational nurse administered Metformin 1000 mg orally and Insulin Lispro 4 units subcutaneously to a resident without providing food, despite physician orders specifying that both medications should be given with meals. At the time of administration, there were no snacks or food present at the resident's bedside, and dinner was not scheduled to be served until later. Review of the resident's physician orders confirmed that Metformin and Insulin Lispro were to be administered with meals for diabetes management. The facility's policy and procedure also required medications to be given in accordance with prescriber orders and at times that enhance optimal therapeutic effect. The interim director of nursing verified the orders and acknowledged that the medications should have been given with food.