Failure to Administer Correct Emergency Medication During Hypoglycemic Crisis
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) failed to administer the correct medication to a resident experiencing a hypoglycemic crisis. The resident, who had a history of diabetes mellitus, end-stage renal disease, and other chronic conditions, was found to have a critically low blood glucose level. Despite having a physician's order for Baqsimi (Glucagon) nasal powder to be administered in such situations, the RN did not provide the prescribed medication. Instead, the RN mistakenly assembled and administered an epinephrine auto-injector with a nasal spray cap, believing it to be Glucagon, and delivered it nasally to the resident. This error was compounded by the involvement of another nurse who assisted in retrieving the emergency kit and handing the incorrect medications to the RN. The resident did not receive the ordered Glucagon, and his blood sugar continued to drop, necessitating emergency medical intervention and subsequent transfer to the hospital, where he was admitted to the intensive care unit. Interviews and documentation revealed that the RN was unfamiliar with the emergency medications and did not verify the medication before administration. The incident was further complicated by initial inaccurate reporting by the RN regarding the medications given. The facility's medication administration policy and the standard nursing practice of verifying the five rights of medication administration were not followed, resulting in the resident not receiving the appropriate treatment for hypoglycemia.
Removal Plan
- All nurses were educated on the use of Emergency Medications by DON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyperglycemia by DON and ADON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- NP was notified of the change in condition and MD notified of the resident being hypoglycemic and being sent to ER.
- V6 and V27 educated on ensuring right medication and dose prior to medication administration by DON.
- All nursing staff educated on the 5R's of medication administration by DON.
- V6 and V27 were educated and completed competency in medication administration on Narcan, Epinephrine, and Baqsimi.
- Nursing staff was educated on medication administration.
- DON or Designees will audit medication administration 2 times a week for 3 months.
- DON or Designee will audit 3 residents 2 times weekly to ensure blood sugars are within normal limit per MD orders for 3 months.
- The emergency kits and the cart will be audited weekly to ensure educational material is in place. This will be ongoing for 3 months and reviewed in our QA meeting. This will be monitored by ADON or designee.
- ADHOC QA completed with IDT regarding Policy and procedure.
- QA to review policy and procedure as part of Quality Assurance Process.
- This will be ongoing for 3 months.