Failure to Prime Insulin Pens Resulting in Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, with surveyors identifying 2 errors out of 36 observed opportunities, resulting in a 5.5% error rate. For one resident with traumatic brain injury, type II diabetes mellitus, muscle weakness, depression, and dysphagia, the care plan directed that medications and insulin be administered as ordered. The physician’s order specified a morning subcutaneous dose of 15 units of insulin Degludec via pen-injector. During continuous observation, an LPN prepared the Degludec insulin pen by attaching the needle, dialing the pen to 15 units, and administering the insulin subcutaneously without priming the pen beforehand. A second resident, with diagnoses including acute and chronic respiratory failure with hypoxia, type II diabetes mellitus, peripheral vascular disease, chronic kidney disease, and hypertension, also had a care plan directing administration of medications and insulin as ordered. The physician’s order required 4 units of insulin Lispro via pen-injector to be given subcutaneously before meals and at bedtime. Observation showed the same LPN dialed the Lispro pen to 4 units and administered the insulin without priming the pen. In a subsequent interview, the LPN confirmed that he did not prime the insulin pens for either resident and stated there was no need to do so. Manufacturer instructions for both the Degludec and Lispro pen-injectors, as well as facility policy, required medications to be administered in accordance with manufacturer specifications, including priming the pens before each injection to remove air and ensure correct dosing.
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