Improper Insulin Pen Priming Leading to Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, resulting in an 8% error rate based on 2 errors out of 25 opportunities. Facility policy on insulin pens required staff to follow proper infection control, storage, administration, and documentation practices, including specific steps for priming the pen: dialing 2 units, holding the pen with the needle pointing upward, tapping to move air bubbles to the top, and pressing the injection button until insulin appeared at the tip, with instructions to discard the pen and notify the nurse/pharmacy if insulin did not appear after 3–4 attempts. The manufacturer’s recommendations similarly directed staff to wipe the pen tip with alcohol, attach the needle, remove both caps, dial 2 units, hold the pen with the needle pointing upwards, and press the button until at least one drop of insulin appeared, repeating as needed before dialing the ordered dose. During one observed insulin administration, an LPN primed an insulin pen while holding it with the needle pointed downward into a trash can, contrary to both facility policy and manufacturer instructions that required the needle to be pointed upward. In a separate observation, an RN attempted to prime an insulin pen while holding it horizontally and leaving the cap on the needle, then dialed 2 units and pushed the dosage button without seeing insulin escape the needle. The RN confirmed priming the pen horizontally with the needle capped and stated this was her usual practice. These observed practices deviated from the required priming procedures and contributed to the calculated medication error rate of 8%.
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