Double Dosing of Insulin Due to Medication Administration Error
Penalty
Summary
A resident with diagnoses including Type 2 Diabetes Mellitus, Alzheimer's Disease, Dementia, and Anxiety Disorder was admitted to the facility and prescribed 27 units of Lantus insulin to be administered subcutaneously at bedtime. On the night in question, two LPNs each administered a full dose of Lantus insulin to the same resident, resulting in a double dose. The first LPN administered the insulin and was unable to immediately document the administration in the Medication Administration Record (MAR) due to computer and internet issues. Subsequently, the second LPN, confused about her assigned residents and not seeing the prior administration on the MAR, also gave the resident the prescribed dose of insulin. Following the double administration, the resident's blood sugar and blood pressure were monitored, with the blood pressure found to be elevated. The on-call physician was notified, and the resident was given glucose gel and snacks as a precaution. The resident was then transferred to a local hospital for evaluation of hypertension, which was reported to be related to the double dose of insulin. Documentation from the hospital confirmed the double dosing incident and the resident's subsequent evaluation.