Failure to Prime Insulin Pens Results in Significant Medication Errors
Penalty
Summary
Staff failed to ensure residents were free from significant medication errors by not priming pre-filled insulin pens before administering insulin to two residents. For one resident with diabetes, kidney disease, obesity, and other conditions, an LPN administered insulin aspart without priming the pen, contrary to manufacturer guidelines that require priming to ensure accurate dosing. The LPN was unable to confirm whether the pen was primed prior to administration. The resident's care plan included monitoring for complications related to diabetes, but the insulin was given while the resident was eating, and the necessary step of priming was omitted. For another resident with diabetes, kidney disease, and additional diagnoses, a different LPN also failed to prime a Basaglar KwikPen before administering the prescribed insulin glargine. The LPN admitted to not priming the pen, despite manufacturer instructions and facility expectations to do so. The DON confirmed that priming is necessary to avoid administering air instead of the correct insulin dose. The facility's insulin administration policy did not specifically address the use of insulin pens, contributing to the medication errors observed.