Double Insulin Dose Leads to Hypoglycemic Episode
Penalty
Summary
A significant medication error occurred when a resident with Type 1 diabetes received a double dose of insulin lispro, along with an additional sliding scale dose, resulting in a total of 27 units of fast-acting insulin administered within a short period. The error was caused by a transcription mistake during the entry of new insulin orders into the computer system, where the previous insulin order was not discontinued. As a result, two licensed nurses administered separate doses of 12 units each, and one nurse also gave an additional 3 units based on a sliding scale order. This led to the resident receiving two scheduled doses only 1 hour and 24 minutes apart, in addition to the sliding scale dose. Following the administration of these insulin doses, the resident experienced a hypoglycemic episode, becoming unresponsive with a blood sugar reading of 43 mg/dl, which was significantly lower than her average blood glucose level. Staff interviews confirmed that the resident was not acting normally and was found to be shaking and unresponsive. The facility's documentation and interviews with the Director of Nursing and other staff acknowledged the medication error, attributing it to a failure to discontinue the prior insulin order, resulting in duplicate administration.