Failure to Properly Prime Insulin Pens Results in Medication Errors
Penalty
Summary
A medication error rate of 6.7% was identified during observation of medication administration, record review, and staff interviews. Two residents with diabetes, both cognitively intact and receiving daily insulin injections, were affected. For one resident, an LPN prepared and administered insulin using a pen-injector but failed to prime the pen before administration, contrary to manufacturer instructions. The LPN confirmed she did not prime the pen and stated she believed it was unnecessary. For another resident, a different LPN primed the insulin pen-injector before attaching the needle, then administered the insulin without priming after the needle was attached. The LPN confirmed this sequence and acknowledged not priming the pen after the needle was in place. Manufacturer instructions reviewed by surveyors specified that priming should occur after the needle is attached and before each injection to ensure the correct dose is delivered. These failures to follow proper insulin pen priming procedures resulted in medication administration errors.