Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate
Penalty
Summary
Surveyors identified a deficiency in medication administration when the facility failed to maintain a medication error rate below five percent, with two errors occurring out of 25 observed opportunities, resulting in an eight percent error rate. During a medication pass, an LPN administered Basaglar (long-acting insulin) and Insulin Lispro (short-acting insulin) via insulin pens to a resident without priming either pen prior to injection. The resident had Type 2 Diabetes, was cognitively intact with a BIMS score of 15, and had physician orders for Basaglar 10 units SC each morning and Insulin Lispro 14 units SC three times daily before meals, which were being administered as ordered per the MAR. During observation, the LPN did not prime the insulin pens before administering the doses. In a subsequent interview, the LPN stated she was not aware that insulin pens needed to be primed and reported she had never primed the resident’s pen prior to insulin administration. The DON stated that facility expectations were that insulin pens be primed with two units of insulin before each injection to ensure an appropriate dose, consistent with the facility’s “Using Insulin Pen Delivery Systems” document, which instructs staff to prime the pen before each injection to remove air bubbles and ensure the needle is open and working.
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