The report also says a nurse didn't tell doctors that bedside blood sugar testing strips differed significantly from lab tests of the patient's blood.
Doctors at Lehigh Valley Hospital-Cedar Crest ordered insulin to lower patient's blood sugar.
But the lab test indicated that the patient's blood sugar was already low after hours of receiving insulin, so the report said continuing to administer it was a critical error.
The patient died Jan. 6. The state report does not name the patient or hospital staff.
The hospital said it cannot comment on patient cases. The hospital also said the patient's family has hired a lawyer.
Information from: The Morning Call