Significant Medication Error: Wrong Insulin Administered
Penalty
Summary
A significant medication error occurred when a nurse administered the wrong insulin to a resident with diagnoses of diabetes mellitus, end stage renal disease, and hypertension. The resident was prescribed Lantus (glargine) and Lispro insulin at specific doses and times, as documented in the physician's orders and Medication Administration Record. However, during medication preparation, the nurse was interrupted and inadvertently gave the resident another patient's insulin, specifically 30 units of NovoLog, which was not prescribed for this resident. Following the administration of the incorrect insulin, the nurse notified the supervisor, and the resident's blood sugar was monitored, revealing a blood glucose level of 354. The resident's family and provider were informed, and the resident was subsequently sent to the emergency department, where she received intravenous D10w. The Director of Nursing confirmed that the facility failed to ensure residents are free from significant medication errors, as required by facility policy and state regulations.