Significant Insulin Transcription Error Leads to Hypoglycemic Event
Penalty
Summary
A significant medication error occurred when a resident with Type 2 Diabetes Mellitus and Diabetic Chronic Kidney Disease was admitted from a local hospital with a physician's order for Lantus insulin 5 units subcutaneously daily. The order was incorrectly transcribed into the electronic medical record by an LPN as Lantus 30 units subcutaneously daily. This error was not identified during the order entry or subsequent reviews, resulting in the resident receiving six consecutive doses of 30 units of Lantus instead of the prescribed 5 units. Multiple nursing staff administered the incorrect insulin dose as documented in the Medication Administration Record (MAR), with each nurse following the erroneous order in the electronic record. The error persisted from the resident's admission until the resident experienced a hypoglycemic episode. On the day of the incident, the resident was found lethargic and unresponsive, with a blood glucose level of 23 mg/dL. Emergency medical services were called, and the resident was treated with intravenous dextrose and transferred to the hospital, where hypoglycemia was confirmed as the diagnosis. Interviews with the involved LPNs, the Clinical Data Coordinator, the DON, and the Nurse Practitioner confirmed that the original hospital order was for 5 units, and the error in transcription led to the administration of 30 units. Staff acknowledged the mistake and confirmed that the MAR reflected the incorrect dose, which was administered as ordered. The incident was recognized as a significant medication error that resulted in immediate jeopardy to the resident's health.