Failure to Prime Insulin Pens Resulting in Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying an 8% error rate during a medication pass observation. During a morning medication pass, RN 1 prepared insulin for Resident G after obtaining a glucometer reading of 285. Based on the resident’s physician orders, this blood sugar level required administration of 6 units of Lispro (Novolog) insulin per sliding scale, and the resident also had a separate order for 46 units of Glargine (Lantus) insulin to be given daily. RN 1 removed two insulin pens from the cart and dialed 46 units on the Lantus pen and 6 units on the Novolog pen. Before administering the insulin, RN 1 entered the resident’s room and was stopped. She then stated she was unsure about priming the insulin pens and did not know the correct way to prime them. The facility’s insulin pen administration policy required priming insulin pens with 2 units of insulin prior to administering the ordered dose. At the time of the survey, the DON reported that RN 1 was new to the facility and had been oriented to the medication pass policies and procedures. Resident G’s record documented a diagnosis of diabetes mellitus and contained the physician’s orders for both the sliding scale Lispro (Novolog) and daily Glargine (Lantus) insulin that were involved in the observed error.
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