Significant Medication Error: Wrong Insulin Administered
Penalty
Summary
A deficiency occurred when a resident with diagnoses of anemia, hypertension, and diabetes mellitus was administered the wrong type of insulin. According to the physician's order, the resident was to receive 30 units of insulin glargine (Lantus), a long-acting insulin, subcutaneously at bedtime. However, during a night medication pass, an LPN administered 30 units of insulin lispro (Humalog), a rapid-acting insulin, instead of the prescribed Lantus. The error was identified by the LPN, who documented the incident and notified the RN supervisor and physician. At the time of the incident, the resident's blood glucose was 170, blood pressure was 134/76, temperature was 97.5°F, heart rate was 74, and oxygen saturation was 98% on room air. The facility's medication administration policy requires staff to verify the right resident, medication, dosage, time, and route before administration, but this protocol was not followed, resulting in a significant medication error for the resident.
Plan Of Correction
Resident R1's orders were clarified, and the order was correct and in place at the time of survey. The residents had no negative outcome from receiving the incorrect insulin. Current residents' insulin orders were audited to ensure that the insulin order for each resident is correct. The DON, or designee, will inservice licensed staff on administering medications policy and administering insulin medication orders policy. The DON, or designee, will conduct an audit on diabetic insulin administration for accuracy of medication orders to ensure that they are given as ordered and documented in the administration record. Audits will be completed weekly for 2 weeks, then monthly for 2 months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.