Although considered by many to be a routine and simple process, diabetes management can be extremely dangerous, and potentially fatal, when handled by inexperienced or poorly trained staff. Errors such as failing to take a consumers blood sugar level regularly or administering inappropriate amounts of insulin, either too much or too little, can have deadly results. In New York State, direct support staff isallowed to perform certain medical procedures, such as administering medications. These staff members are commonly known in the mental retardation/developmental disabilitiesfield as Approved Medication Administration Personnel (AMAP), and are allowed to perform certain medical procedures as long as they are adequately trained by a supervising, NYS licensed, registered nurse.

Ms. Elena (*a pseudonym) was a 70 year-old woman with moderate mental retardation, Down syndrome, and diabetes mellitus type I, for which she received insulin to control her fluctuating blood sugar levels. Despite her diagnoses, Ms. Elena was relatively high functioning and ambulatory, and was approved by her residence to administer her own insulin injections.

On July 3, at approximately 6:45 a.m., staff attempted to wake up Ms. Elena for morning medications. Staff found her unresponsive, with labored breathing, and noticed that she had been incontinent at some time during the night. Staff called 911 and she was taken to a local emergency room, where she reportedly had a grand mal seizure. She was admitted to the ICU and was placed on a ventilator. Her condition remained stable until July 6, at which timeher condition rapidly deteriorated and she died.

An investigation into Ms. Elenas condition on the morning of July 3, revealed errors in diabetes management which led directly to her death several days later. Just prior to bedtime on July 2, Ms. Elenas blood sugar was taken and determined to be within a normal range.

The staff member assisting Ms. Elena, who had concerns that the blood sugar level was too low, contacted several residence administrators, who instructed the staff member to proceed with Ms.Elenas regular 10 p.m. insulin injection. The staff member, who was AMAP certified by the agency, assisted Ms. Elena with the preparation of the injection so that Ms. Elena could administer the injection, as was routine practice. To administer her medication, Ms. Elena normally used an insulin pen, which contains a cartridge that holds the insulin and closes like a large pen. An insulin pen is considered to be relatively easy to use and is especially convenient for individuals who have to take several injections a day. Insulin that is currently available in the United States has been standardized so that each cubic centimeter (cc) of medication contains 100 units of insulin. It is administered via a specially designed syringe, or pen-type device, that is calibrated in units, not ccs, and is utilized solely for insulin products.

However, Ms. Elenas insulin pen broke several days earlier, so staff were forced to use a regular syringe and manually draw up Ms. Elenas insulin until a new pen could be obtained at the local pharmacy. What the agency nurse did not know, however, was that the AMAP certified staff member who assisted Ms. Elenawith preparing the insulin injection had never prepared this type of medication before, was not trained in using a regular insulin syringe, and was not adequately trained in diabetes management practices.

Ms. Elena was prescribed, and regularly took, 6 units of insulin. For reasons not fully understood, the AMAP certified staff member assigned to assist Ms. Elena with her insulin drew the insulin to the 50 unit mark on the syringe instead of the 6 unit mark and handed the syringe to Ms. Elena. Due to her cognitive impairments, Ms. Elena was incapable of checking the dose of insulin handed to her and self-administered almost nine times the amount of insulin prescribed for her.

Ms. Elenas blood sugar level dropped precariously low during the sleeping hours,sending her into hypoglycemic shock. Blood sugar levels are normally between 70 and 110 milligrams per deciliter (mg/dL). Ms. Elenas blood sugar level, taken in the emergency room after being found unresponsive in her bed that morning, was 13 mg/dL.

While the ultimate responsibility lies with the licensed nurse who certifies AMAPs to perform procedures under his/her nursing license, agencies can take steps to ensure that all staff who perform diabetes management procedures are adequately trained. In the case cited above, the AMAPs error directly contributed to the death of a consumer. The AMAP was not properly trained or educated in diabetes management issues, leading to the fatal error. The Commission strongly recommends that agencies mandate all AMAPs who manage consumers with diabetes receive rigorous training in diabetes management, including both an educational and practicum component. Because even minor errors in diabetes management can have a significant negative, or even a fatal, impact on consumers, staff should be closely supervised by nursing staff until they have displayed competency in the various procedures. Further, it would be prudent for agencies to consult with diabetes experts, such as staff from the American Diabetes Association or a certified diabetes educator, to ensure that the procedures in practice at the agency are current and appropriate.

From this case study can you please explain these 4 questions.

1) summary of issues presented

2) description of parties involved

3) potential causes of problems

4) how you would have handled the issue differently.