Insulin Administration Error Due to Distraction and Protocol Lapses
Penalty
Summary
A medication administration error occurred when a nurse administered 20 units of Novolog, a rapid-acting insulin, instead of the physician-ordered 20 units of Lantus, a long-acting insulin, to a resident with diabetes. The resident's care plan and physician orders specified the use of Lantus at bedtime and Novolog only per sliding scale or with meals, depending on blood sugar readings and meal intake. On the evening of the incident, the nurse became distracted by questions from other residents and staff while preparing the insulin at the medication cart, leading to the selection and administration of the wrong insulin type and dose. The error was discovered after the insulin was administered, and the nurse realized the mistake upon returning to the medication cart. The resident's blood sugar was monitored, and the nurse contacted the DON and the on-call provider. The resident was subsequently sent to the emergency room for evaluation and treatment. Medical records indicate the resident experienced a hypoglycemic reaction and required administration of dextrose, glucagon, and glucose tablets. The resident remained neurologically intact and was monitored until blood sugar levels stabilized before being discharged back to the facility. Interviews with staff and review of facility policies revealed that the nurse did not follow the rights of medication administration, was distracted during medication preparation, and failed to verify the medication against the EMAR and physician orders. The root cause analysis identified distraction, lack of communication between nurses, and failure to adhere to established medication administration protocols as contributing factors to the incident. The resident, who had a history of diabetes and was cognitively intact, received the incorrect insulin due to these lapses.