Significant Insulin Dosing Error Due to Duplicate Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration. The facility’s own Medication Administration Assistance Policy, dated 04/2017, requires staff to check the medication order for proper route, dose, time, strength, frequency, and type, and to notify the physician immediately of problems with medications. The resident, who had Type I diabetes mellitus with hyperglycemia, long-term insulin use, and unspecified cognitive symptoms, was admitted on a specified date and had physician orders for Insulin Glargine-yfgn 15 units at bedtime for diabetes. Physician orders dated over two consecutive days both directed administration of 15 units of Insulin Glargine-yfgn at bedtime, creating duplicate orders for the same long-acting insulin. Record review of the Medication Error Incident Report showed that the resident received the wrong dose of insulin when 17 units of long-acting insulin were administered instead of the ordered 15 units. The incorrect order and dosing error were not identified by the physician until several days later, during which time the resident experienced low blood sugars for multiple days after the additional administration. The Medication Administration Record confirmed that both insulin orders remained active until they were discontinued on the same later date. During an interview, the DON acknowledged that a medication error occurred and that the resident received a duplicate insulin order for several days and should not have, and stated that her expectation is that all residents receive correct medications and dosages per physician orders.
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