Significant Insulin Medication Error Due to Incorrect Dose Administration
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and a diagnosis of diabetes mellitus was administered 60 units of Humulin NPH insulin instead of the physician-ordered 6 units. The error was made by an LPN who was employed through a nursing agency and was responsible for drawing up the insulin from a vial, as the resident did not have an insulin pen. The LPN believed they had drawn up the correct dose but realized after administration, while entering the dose into the medication administration record, that 60 units had been given instead of 6 units. The resident's blood glucose readings before and after the administration were documented as 163 mg/dl and 189 mg/dl, respectively. Upon discovery of the error, the LPN immediately reported the incident to the nursing supervisor. The supervisor assessed the resident, who was found to be alert with stable vital signs and no signs or symptoms of hypoglycemia at that time. The incident was also reported to the physician assistant, DON, and the resident's family. The resident was subsequently transferred to the hospital for observation due to the increased risk of hypoglycemia following the administration of the excessive insulin dose. Documentation and interviews confirmed that the LPN had not previously undergone medication pass observation by the supervisor prior to the incident. The facility's records and staff interviews corroborated the sequence of events leading to the medication error.