Medication Error: Epinephrine Administered Instead of Glucagon
Penalty
Summary
A significant medication error occurred when a nurse administered Epinephrine instead of Glucagon to a resident who was experiencing hypoglycemia. The resident, who had a history of diabetes, hypertension, and a recent femur fracture, was found to have a low blood glucose level of 59 mg/dl and was unable to take oral glucose. The nurse, after being unable to access the medication room on her unit, obtained emergency medications from another unit. She was handed both Glucagon and an EpiPen by another nurse, and despite reading the instructions for Glucagon, mistakenly administered the EpiPen. The nurse did not realize the error until the following day when informed by the facility administrator. The facility's medication administration policy required staff to verify the right resident, medication, dosage, time, and route before administration. The resident did not have a physician's order for Epinephrine, only for Glucagon to be given intramuscularly for blood sugar less than 70 mg/dl if unresponsive or unable to swallow. The error was identified through review of records and staff interviews, and the Director of Nursing confirmed that the nurse failed to ensure the correct medication was administered.