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MAINEGENERAL MEDICAL CENTER
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on document reviews and interviews, the hospital failed to ensure insulin was administered in accordance with the provider's orders one (1) out of twenty (20) sampled patients (Patient #2).
Findings:
1. Patient #2's medical record was reviewed and revealed that Patient #2 had a history of type 1 diabetes.
2. Patient #2's medical record contained a Physician Note by Physician #1 dated 02/11/2024 at 2:25 PM which reads in part:
" ...Physician Note REASON FOR ADMISSION: Diabetic ketoacidosis ..."
3. Patient #2's medical record contained an order for regular insulin dated 01/29/2024 at 5:31 PM. The order stated a dose of insulin was ordered for 20:00 (8 PM) on 01/29/2024. The order reads in part:
" ...01/29/2024 17:31 Insulin Reg (S/S) U100 Ordered by: [Physician #2]
{FALL RISK} (High Alert Drug), Injection, SubCutaneous,
4. Patient #2's medical record contained an entry stating a Glucose Meter, Point of Care blood glucose level was obtained and Patient #2's blood glucose level was 445 at 8:36 PM on 01/29/2024.
5. Patient #2's medical record showed that the 8 PM ordered dose of insulin was not administered until at 9:59 PM on 01/29/202, with 13 units of regular insulin administered by RN #1. This was 1 hour and 59 minutes after the ordered administration time, and 1 hour and 23 minutes after the point of care blood glucose level of 445 was obtained.
6. At 9:30 AM on 02/14/2024 a telephone interview was conducted with Physician # 3, one of the physicians who was caring for Patient #2 on 01/29/2024.
During the interview Physician #3 was asked, "What are the risks associated with a blood glucose level of 445 in a patient who has type 1 diabetes?":
Physician #3 stated that if the patient became hyperglycemic (high blood sugar), they could become dehydrated if they lose too much glucose in the urine. She stated that generally patients could potentially go into Diabetic Ketoacidosis (DKA) if they don't have enough endogenous insulin, which she stated is why they should always have either long acting or short acting insulin on board.
Physician #3 was asked, "For a patient with type 1 diabetes who has a blood glucose level of 445, and an ordered dose of insulin which was available to be administered immediately, what is an acceptable timeframe for the administration of the dose of insulin?":
At 9:31 AM on 02/14/2024 Physician #3 stated that the dose of insulin should be administered within an hour at the most of the scheduled administration time.
Physician #3 stated, "It depends on what else is going on, but the patient could potentially go into DKA if they do not receive the insulin in an hour."
Physician #3 stated the risks of DKA could be that the patient could become dehydrated and become unstable. Physician #3 additionally stated there could be a lot of electrolyte imbalances, which could lead to downstream multiorgan failure.