Medication Error Rate Exceeds 5% Due to Improper Insulin Pen Administration
Penalty
Summary
A medication error rate of 8% was identified during a medication administration observation, with two errors occurring out of 25 opportunities. The errors involved a licensed vocational nurse (LVN) administering prefilled insulin pens (Humalog and Lispro) to two residents with diabetes. In both cases, the LVN failed to hold the dose knob of the insulin pen in place for at least 5 seconds after injection, as required by the manufacturer's instructions. Instead, the LVN pressed and immediately released the dose knob, which could have resulted in the residents not receiving the full prescribed dose of insulin. The medical records for both residents showed active physician orders for subcutaneous insulin administration before meals. During interviews, the LVN acknowledged not being aware of the requirement to hold the dose knob for 5 seconds. The Director of Nursing (DON) confirmed, after reviewing the manufacturer's instructions, that the correct procedure was not followed during the observed medication passes. The facility's policy on subcutaneous medication administration also indicated that medication should be injected slowly.