Significant Insulin Medication Error Resulting in ICU Admission
Penalty
Summary
A significant medication error occurred when a nurse administered 100 units of short-acting insulin to a resident instead of the prescribed 3 units. The error was due to the nurse misreading the insulin order, confusing the medication strength (100 units/ml) with the dose to be given. The nurse, who had limited experience with insulin administration and was new to bedside nursing in long-term care, did not seek clarification despite noticing the unusually large volume drawn up. The nurse also reported that another resident was prescribed a high dose of insulin, which contributed to her assumption that the dose was correct. The resident involved had a medical history including necrotizing fasciitis, type 2 diabetes mellitus, and a recent diagnosis of hypoglycemia. After receiving the excessive insulin dose, the resident experienced dizziness and a significant drop in blood sugar, requiring emergency intervention. The resident was given glucose by EMS or facility staff and was subsequently hospitalized in the intensive care unit for management of hypoglycemia. Record review and staff interviews confirmed that the nurse did not verify the correct dose before administration and failed to follow the facility's medication administration policy, which requires confirmation of the right dose. The incident was documented in the resident's clinical record, progress notes, and an incident report, all indicating that the error was recognized after administration and emergency measures were taken.