Medication Administration Errors and Failure to Follow Inhaler and Insulin Pen Instructions
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 4 errors out of 26 opportunities (15.38%) during medication administration observations. For one resident with COPD and moderately impaired cognition, physician orders included a daily fluticasone nasal spray, a twice-daily budesonide/glycopyrrolate/formoterol steroid inhaler with instructions to rinse the mouth after use, and albuterol inhaler four times daily. During a medication pass, a nurse handed the resident the nasal spray and two inhalers and allowed her to self-administer without providing instructions. The resident then administered two sprays of the nasal spray in each nostril and three puffs of albuterol, exceeding the ordered doses, and after using the steroid inhaler, the nurse did not instruct her to rinse her mouth with water as ordered. The nurse later acknowledged awareness that the resident had taken too many puffs of the nasal and albuterol inhalers and that the steroid inhaler required a post-use mouth rinse to prevent oral thrush but stated he did not think about it at the time. In a separate incident, another resident with diabetes mellitus had a physician order for 8 units of Lispro insulin subcutaneously before meals when blood sugar was between 301 and 350. During an observed insulin administration using a prefilled insulin pen, a nurse removed the Lispro pen from the medication cart, dialed the dose directly to 8 units, and administered the insulin without priming the pen as required by the manufacturer's instructions. The manufacturer’s directions specified priming the pen each time by dialing 2 units, pressing the injection button to expel air and confirm insulin flow, and checking for a drop of insulin at the needle tip, repeating if necessary. When questioned, the nurse stated she followed the five rights of medication administration but then acknowledged she was aware of the need to prime the pen and realized she had forgotten to perform this step. The consultant pharmacist and DON confirmed that residents should be instructed on inhaler use, including mouth rinsing after steroid inhalers, and that insulin pens must be primed to remove air and ensure full dosing.
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