Reducing drug errors by engaging student nurses in medication management simulation

With the discussion of drug errors being raised around the world, there are concerns for patient safety. Nurses should understand the complex issues related to being safe while involved in any aspect of medications management and should be able to practise these at undergraduate level using simulation. Simulation allows student nurses to practise the safe administration of drugs and apply strategies that are supported by evidence and pharmacological knowledge.

Medicine use can be complex. Helping to educate people to take their medicines safely and effectively has been a longstanding challenge for health and social care practitioners. Therefore, students were provided with the opportunity to enact scenarios related to improving their knowledge and skills in medication management during skills modules.

Background

The historical roots of simulation for the practice of skills, problem solving and judgment are evident in work carried out by Rosen (2008). McCaughey and Traynor (2010) have demonstrated that simulation has a role in higher education. Simulation using case scenarios has been used by Edwards et al (2018a; 2018b) as a positive teaching strategy.

There needs to be room for simulation of practice in higher education, which can be made realistic by using real life case studies from students' own practice. Using real life case scenarios provides the appearance of authentic practice in simulation, and is a way that nurse education can use different learning strategies to better prepare students to assume increasingly complex roles that require a high level of critical thinking and clinical judgment (Lasater, 2007). Students and lecturers in the university were already well-versed in using case scenarios as a basis for simulation (Edwards et al, 2018a; 2018b; Edwards and McCormack, 2018).

Simulation has been reported to improve teamwork and self-confidence (Kakora-Shiner, 2009). Combined with debrief and reflection (Barata et al, 2006), medication management simulation could reduce the risk of future medication errors. Reflecting on an experience or performance provides an opportunity to improve and further develop knowledge (Nursing and Midwifery Council, 2018). Medication management simulations in nurse education can provide relevant skills, opportunities to apply research findings regarding medication management practice and different roles for students to engage in, with the opportunity for debrief and immediate feedback on their performance. Drawing on these ideas and the previous work of authors, this project developed and created medication management simulations for undergraduate nursing students.

Design

According to Cant and Cooper (2010), there can be a risk of high anxiety and intimidation when using simulation-based learning. Thus, the role of the facilitator was crucial in ensuring students and staff were provided with the necessary preparation. First, students were given the knowledge and information to be able to get involved. This ensured students understood why medication management simulations were going to be introduced into the skills modules.

The simulations were designed to be student-led at the bedside and included students adopting patient roles to ensure a more real life feel to the experience of a drug round. Props were also included to give the feel of a real four-bedded bay environment.

Student as patient role: student volunteers

It was felt that the medication management simulations using medium-fidelity manikins was not appropriate because patient interaction is essential in medication management. Therefore, the medication management simulation used fellow students playing the role of patients.

Student volunteers agreed to rotate playing the role of at least one of the four different patients. They were provided with a guide and some cue questions to help them challenge the student nurses doing the medication management simulation.

The student lead role

It would be difficult for one facilitator to manage a four-bedded bay drug round with four simulated patients requiring drug administration. Therefore, a student lead role was created for each simulation and each of the four patients. A script was provided for the student lead with an outline of the moment-to-moment plan of the flow of the drug administration for each of the four different patients. The student lead guided the drug round simulation process using the script provided. The student lead offered monitoring information that could not be known (eg temperature), prompting and guiding when interventions or care was missed or incomplete.

The project took a collaborative approach, providing students with a progressive learning environment to prepare them for leadership roles.

Props and learning and teaching materials

Props were used to simulate a real ward, such as patients' personal items (magazines, sweets), water jugs, and individual bedside medication cabinets that contained the ‘patients’ prescribed medications. Moulage was incorporated to add authenticity to the simulations, with the addition of sputum pots containing ‘made up’ sputum, similar to what would be produced by the patient.

Background sounds of an everyday ward were provided to engage the students' senses, encouraging them to concentrate on the drug round and not be distracted, which is a major cause of drug errors (Edwards and Axe, 2015; 2018). In addition, there were learning and teaching materials such as the drug charts, nursing notes, observation charts, fluid balance charts and handover sheets.

The medication management simulation

There were four different case scenarios provided for two different student medication management simulations for 2nd and 3rd year students (Tables 1 and 2). These were put together to help students recognise their responsibilities when undertaking drug administration. The students commented on the scenarios in their feedback:

‘Scenarios were interesting and arranged in such a way as to make the session more enjoyable.’

‘Enjoyed understanding each patient scenario their conditions and medications.’

‘Having a simulation with different scenarios to work on.’

The scenarios seemed to improve the students' knowledge of the systems and processes involved in medicines management and their application to practice.

Pre-reading and preparation

The students were provided with detailed information about the simulation at least 1 week before the simulations took place. This included a lesson outline. The information sheet showed how the simulation would be organised, as it was essential that all students carried out a drug round, not just four individual drug administrations (Figure 1).

The patient cues for the students who played these roles and student lead scripts were also placed on the virtual learning environment before the simulation and at the bedside on the day of the simulation. Students were recommended to read the learning and teaching materials carefully beforehand. The students valued this information and mentioned its value in their feedback:

‘Reading through the preparation materials helped me to be more effective during the medication management simulation.’

‘Preparing for the session using the information provided was valuable to my experience.’

‘Good preparation information for the nurse, patient and student lead, well written and clear to follow.’

All of the students were made aware at the outset that this was a ward situation and each group was administering medications prescribed for each patient in the four-bedded bay area, as a drug round. All the relevant bedside charts and drugs were provided at the patient's bedside.

Debriefing

At the end of each medication management simulation, debriefing took place. Debriefing is considered the most important phase of simulation (Kang and Yu, 2018), and according to Johnson-Russell and Bailey (2008) is where 80% of learning occurs. Debriefing should take place following simulation to enhance learning, which can either be instructor- or student-led (Fey et al, 2014). The medication management simulation used both instructor- and student-led debriefing.

Students directed the debrief by identifying their own strengths and weaknesses and drew out meaningful elements of their simulation experience. The instructor-guided debrief asked students to analyse and synthesise their feelings and behaviours using Driscoll's (2007) ‘What, So what and Now what’ reflection-on-action model.

The use of two debriefing methods is a key learning element, to ensure both educational development and emotional support is delivered in a safe environment. It allows students to gain a better insight into their practice and become active, dynamic participants in their learning.

Student evaluation

Student feedback and evaluations were gathered through the completion of structured evaluation forms, formal discussion, and debrief sessions. The emerging themes from the students' feedback were about learning in the past, present and future; challenging and reflection, questioning practice; sensing and experiencing in real time and leading in the moment (Table 3).

Continuity

Clandinin and Connelly (2000) used the concept of continuity to denote the passage of time that links past, present and future with regards to how students are learning. This can be applied to the student learning gained from the medication management simulation.

Students seemed to be taking what they had learned in the past to help them refresh their knowledge, build on their confidence, remember the ‘rights’ (Table 4) and revise their knowledge of medications:

‘Build on my confidence already gained in clinical practice.’

‘It helped me to brush up on the medications that I had forgotten, and familiarise myself with the drug routes allowed again before the simulation.’

The student experiences from their past were applied into the present when they were concentrating on the drug round, practising the skill of medication management and learning new terminology:

‘Concentrating on the drug round and not allowing your attention to be drawn by other things going on in the ward.’

Students took their learning into the future for their role as a nurse:

‘I need to read up on the different types of medications and what they are for.’

The students at all times seemed to have ‘being safe’ and ‘improving safety’ as a high priority.

The students were challenged

In order to develop a positive learning environment with simulation, it is important to ask questions to challenge each other, as this mimics real life healthcare situations. Through the medication management simulation, students gained a more questioning and challenging approach. This approach should be exercised to prevent risk and ensure safety. The students voiced how they were challenged by each other:

‘The student nurse playing the patient was challenging and difficult, which could happen in practice and I need to deal with it.’

Students also learned to challenge by asking questions. The development of good questioning skills to themselves is represented in the feedback:

‘Good to get us thinking about the effects of medications and our approaches to the patient.’

‘It got me thinking, to question everything and check everything.’

‘It gives you more knowledge about what questions to ask so there are less drug errors in practice.’

A more questioning and challenging approach is recommended in clinical practice as it supports professionalism. However, Pian-Smith et al (2009) highlight the difficulty in asking questions, expressing disagreement or challenging the actions of superiors. Nevertheless, appropriate questioning has the potential to improve patient safety and foster a healthy learning environment. The medication management simulation can ensure drug safety measures are being learned early as a defence against the occurrence of drug errors.

A challenging and questioning approach is vital to professional development. Indeed, appropriate challenges and questioning have the ability to develop a culture of openness and improve patient safety.

Student nurses were learning deep-thinking skills about issues related to medication management practice:

‘The medication management got me to think deeper and critically about how medication affects the patients.’

‘The critical thinking involved, being prepared to answer patient questions.’

The students were asked to play different roles, which was challenging, but helped them to understand the needs of the people they played:

‘I enjoyed the opportunity to play the different roles, eg patient, nurse, student lead, so I could experience each side of medication management and learn from each other.’

‘Having the opportunity to be lead, be the patient and nurse.’

The process of enabling students to understand different roles is crucial to becoming an effective nurse. The students' perspectives were enhanced by playing the different roles to deepen understanding of their profession. They moved from focusing on their own experience to thinking about how patients or leaders experience what they do, which was challenging, but provided them with a positive learning environment.

The students sensed the experience in real time

The students ‘sense’ the environment around them and have to deal with the reality of the experience:

‘The different scenarios felt real and helped me to understand pharmacology.’

‘Giving medication and understanding and interpreting a real written drug chart.’

‘Being able to administer medications in a real situation set up.’

Effective nursing care does not just rely on engagement and treatment, but involves all the senses (Edwards et al, 2018b). The medication management simulation enabled students to experience practice in a way that connected practical subjects to the academic part of their course, bringing both to life. Students were engaged with the complexities of real-life interactions and were part of the experience while at the same time learning from it:

‘It was a realistic simulation and I felt it was real and interesting. Very similar to drug rounds on the wards.’

‘It was realistic to the ward and you were pressured for time, so had to work efficiently, safely and quickly.’

Leading in the moment

Perkins (2007) highlighted how handing over control of a scenario from teachers and instructors to learners and students promotes self-evaluation, which is re-inforced by feedback:

‘I was happy with my student lead role, as I was able to see how others get things right without being under pressure.’

‘Got to play this very important role and to observe how others work so I can see where I can improve.’

Thus, the use of the student-lead role can prepare students for their later leadership roles:

‘I liked practising skills I would use as a nurse independently and getting feedback.’

‘I have learned more because it was a student-led session.’

In addition, student-led simulations contributed to students' professional development, and exposed them to situations that can affect their future professional roles and patient care.

Discussion

The issue of drug errors was discussed in a speech on patient safety by former Secretary of State for Health and Social Care, Jeremy Hunt and reported in many of the mainstream media. The articles (The Guardian, 2018; The Independent, 2018; The Times, 2018) discuss the mistakes that occur in medication management and how these can cause avoidable ‘harm and death’. As a result, there has been a drive to reduce drug errors, but for this to occur, medication management needs to be at the forefront of nurse education. This medication management simulation was an attempt to engage students early in safe medication management practice. Students seemed to be engaging in the ‘rights’ approach, making decisions, learning about safe medication management practice and how they might prevent them.

The use of the ‘rights’ approach

To ensure safe medication management, nurses are encouraged to follow the 5 ‘rights’ to help prevent errors. In the evaluations, students mentioned how the inclusion of the 5 rights could ensure safe practice and mitigate against drug errors:

‘To check the drug charts, incorporate the 5 rights.’

More students recognised there are now 6 or 7 rights.

‘How important it is to read through and check the whole drug chart, and apply the 7 rights.’

‘It is very important to remember the 7 rights of medication, as a professional it is very important to administer correct medication for patient safety.’

‘I learned how to give medications properly, following the 7 rights.’

‘There are now 7 rights rather than 6 rights.’

Despite the different opinions about the various rights (Table 4), these rights generally relate to drug administration and not to the whole medication management trajectory. Choo et al (2010) and Redman (2017) have said that none of the rights account for human, environmental and system errors. This is not to say that checklists are not useful, but perhaps they need to be further developed or expanded in some way that encompasses a broader approach.

Maintaining safe practice during drug rounds

A drug error can occur at any stage of the drug chemical preparation/prescription/outcome journey. Elliott and Liu (2010) suggested that only a small proportion (between 26–38%) of drug errors are nursing-related. One student stated the importance of a multidisciplinary approach to medication administration:

‘To understand safe multidisciplinary drug administration.’

However, just using numerical data to show the incidence of drug errors is not helpful, as it implies less is better. Other factors contribute to drug errors and through the medication management simulations students were beginning to consider them.

The student feedback identified that errors can occur due to the environment where clinicians work. Pape et al (2005) found that distractions, noise and poor lighting could contribute to drug errors. In the medication management simulation it was important to reflect this:

‘Enjoyed administering the medicine on my own as a staff nurse with background noise made the simulation room like a ward.’

‘In a busy environment the basic things can be forgotten such as the 7 rights, double-checking.’

Johnson et al (2017) discussed the effect of interruptions on the occurrence of medication management. Students learned about the importance of distractions and concentration in the medication management simulation:

‘The nurses should concentrate and should not be distracted while conducting a medication round.’

‘To focus and concentrate under pressure.’

Jones (2009) examined the evidence relating to the causes of medication administration errors and methods to reduce such errors. In their feedback, students were demonstrating insight into their role in the prevention of drug errors:

‘If I am not sure about the drug I am administering, I need to check the drug in the BNF.

’ ‘How important it is to administer and check medication so it is given to the patient on time.’

‘It made me more aware of the correct medication management processes to prevent mistakes.’

‘To always check and double check patient's details, medications.’

‘Made me think about all the possible risks to consider, be alert and properly check the drug chart.’

‘Made me become more aware and careful when administering medications.’

‘Remember to check date on each medication.’

Human or personal factors such as poor calculation competency or violation of double-checking practices (if a recommended hospital protocol) has been identified as major contributors to drug errors. According to Durham (2015), human and personal factors are unintentional and unpredictable. Edwards and Axe (2018) highlighted that the cause of drug errors are multifaceted. Drug errors are often blamed on nurses' poor numeracy and calculation skills; however, the literature examined by Wright (2010) suggested that there were more pressing aspects of nurses' preparation and administration of drugs that require urgent attention. One student recognised the importance of checking everything, not just the calculation:

‘The drugs digoxin and furosemide and the need to check heart rate and potassium levels, the drug calculation.’

Decision-making

Edwards and Axe (2015) proposed a different approach, which recognises the 5 rights of drug administration, but acknowledges that medication management extends beyond drug administration by proposing a 10 rights approach (Table 4). The 10 rights approach considers the full medication trajectory of medication management from before administration to after administration. It also identifies other skills and competencies required for safer medication management.

The scenarios for the 3rd year student simulations were designed and created to prompt students to make decisions. Through this process the additional 5 rights, the right to refuse, knowledge, questioning/challenging, advice and the expected response/outcome during the medication management simulation could be manifested. The students need to critically analyse the situation while undertaking the simulation at the bedside and respond appropriately for the patient who is, for example, hypokalaemic, or presented with bronchocontriction or determine if an alternative route is required. The students' actions then had implications for practice, which they needed to be clear of. This built on their development of critical decision-making skills and combine it with other knowledge and skills, which in the 3rd year group evaluations brought out more of the additional 10 rights.

The 5, 6, 7, 8 or 9 rights approaches as protocols, policies or checklists to safer drug administration can restrict professionals' competency and ability to make autonomous decisions. However, the Edwards and Axe (2015) approach embraces and encourages the use of professional judgement, and requires a level of knowledge to undertake medications management and competence. In addition, it values the inclusion of discretion in safe medication management, and the complex thought processes required.

The students' feedback mentioned how the medication management simulation was developing their decision-making skills:

‘Making the decisions whether to consult with the doctor if some medication is written up incorrectly or it needs to be withheld due to the patient's condition.’

‘Getting to understand the different reasons why you would or would not give certain medications and in what situations this would apply.’

‘Re-enacting the role of the nurse figuring out reasons medication could or could not be administered.’

‘That pharmacology is important and that we need to know about drugs that may need to be omitted due to changing levels of potassium or heart rate.’

The 10 rights approach to safer medication management is not a checklist, but more of a guide to self-managed decision-making for professionals, which encourages self-regulation. Students were showing signs of early development of these skills:

‘I need to prioritise my tasks and how easily mistakes can be made if drugs are given without thought or clear decisions.’

‘Our group noticed the errors on the drug chart and had to work out how to deal with the situation.’

This insight into the students' ability to check their own practice is in keeping with the ‘right-touch’ approach to professional practice (Professional Standards Authority, 2015) in conjunction with a number of different agencies such as the NMC (2018). The risk to patients will never completely be eliminated, but attempts need to be made and approaches updated as new evidence emerges to reduce risk and move closer towards safer practice.

Students were learning how to reduce the incidence of drug errors

Latimer et al (2017) suggested that in order to reduce medication errors, strategies that increase nursing students' awareness of medication errors should be taught. There is some agreement over what strategies can be put into place. Students were beginning to learn how they could, in practice and in the future, reduce the incidence of drug errors.

Improving communication

Students were provided with red tabards to notify other students that they were carrying out the drug round. This reflected how student nurses modified their practice to enhance patient safety and to reduce drug errors. Hayes et al (2015) undertook a review into how interruptions during medication preparation and administration could sometimes be associated with medication errors; therefore, to reduce interruptions, students in the simulations wore tabards. The student nurses were learning to stay focused and manage these interruptions:

‘When undertaking a drug round you need to focus very carefully on what you are doing, and not be easily distracted.’

Patients and staff are discouraged from disturbing a nurse who is wearing a red tabard indicating they are administering medications. However, there has been limited research to suggest that the wearing of a tabard reduces drug errors or into its effectiveness in reducing human factor errors in drug administration (Edwards and Axe, 2015; 2018).

The quality of team communication has been linked to improvements in patient clinical outcomes (Institute for Healthcare Communication, 2011). Therefore, it is conceivable that any links to a reduction in medication errors, due to the wearing of a tabard, is more likely to occur due to an improvement in team communication:

‘I learned that communication is important and if unsure make sure to ask.’

‘When undertaking a drug round it is important that you have listened to the handover and continue to refer to it is important.’

Students gained experience of better communication, as when they were wearing a tabard all team members were aware that a drug round was being performed and therefore distractions and the incidence of drug errors were reduced.

Information technology

Attempts to reduce medication errors due to faulty system factors have included the introduction of information technologies. Yet, there is resistance to adopting these technologies due to the expense to implement and maintain, and issues with patient privacy. Cabilan et al (2017) noted that these technologies were reliant on user input to ensure patient data is accurate and complete.

One student mentioned in their feedback the use of Datix software to improve the reporting of errors and so improve patient safety. Technologies such as Computer Physician Order Entry and others may be seen to reduce risk to patients, but may create new problems such as ‘alert fatigue’ (Cabilan et al, 2017) and ease of overriding current safety systems. Goddard et al (2012) discussed how professionals could rely too much on technology to provide clinical decision support rather than using their own judgement. According to Durham (2015), more studies need to be carried out to explore the impact of technologies on the reduction of drug errors.

Implementing evidence and improving knowledge and understanding

All prescribing and non-prescribing professionals must aim to provide safe, evidence-based medication management.

Westbrook et al (2010) contributed to the understanding of the effects of interruptions on medication administration errors. If a nurse has read the available literature on what contributes to the occurrence of a drug error, perhaps additional care will be taken during busy times while undertaking a drug round, as this is when errors are more likely to occur.

Improving knowledge of pharmacology can also reduce drug errors. Edwards and Axe (2015) identified the need for nurses to have knowledge of pharmacology, which can reduce the occurrence of drug errors during medication management, and this was referred to in the student feedback:

‘Learned about the pharmacokinetics and pharmacodynamics of the presented medications.’

‘About the different medications, administration, medicines to different patients and drug interactions.’

‘Understanding the drugs given and why we give them, what they were for and how they can help the patient.’

‘A good opportunity to put theory into practice.’

However, a nurse involved in medications management not only needs to have knowledge, but also needs to apply understanding. For example, understanding could lead to the omission of furosemide on the grounds the patient's potassium level is too low (by checking daily blood results); or digoxin, as the redial pulses were below 60 beats per minute or the patient has a bradycardia. Students recognised this in their feedback:

‘The drug round need to check blood to identify potassium levels with furosemide.’

‘Learned more about furosemide and digoxin.’

‘Furosemide – the side effects and that it is important to check potassium levels, taught me to check side effects.’

Nurses in clinical practice who are administering drugs should aim to have this level of knowledge and understanding.

Registered and student nurses, doctors, health care assistants, pharmacists and allied health professionals have a duty to ensure the staff directly involved or delegated to administer medicines have sufficient knowledge to undertake the task safely. It is important that they have an understanding of the drug before administration, the indications, contraindications, be able to explain it to the patient, the clinical outcome of its administration and to recognise the relevant side-effects.

Medication management without the application of evidence-based practice or knowledge and understanding fails to represent nurses as autonomous knowledgeable practitioners who are able to use their own clinical judgement without the fear of being accused of a drug error.

Providing better medication advice

All health professionals who prescribe or administer a drug should be able to provide medicine advice about actions, and indications of all medications, side effects, importance of taking a drug at the correct time and the expected outcome of the drug(s). This can prevent the occurrence of drug errors during medication management. Students wanted to do this better for their patients and felt their involvement in the medication management simulation supported this:

‘To be able to give more information to the patients.’

‘I have improved my abilities to explain and answer the questions from patients.’

‘How to work with individual patients.’

‘I felt confident in my knowledge to be able to explain things to the patient.’

The NMC (2018) recommends that nurses should follow appropriate guidelines when giving advice about medicines and act only if they have enough knowledge about the person's health needs and if they take into account other care the person is receiving. All health professionals have a responsibility to communicate these essential factors in order to contribute to the therapeutic relationship between the clinician and patient, and help improve medication adherence.

Reflections

The students who took part in the simulation said they enjoyed the experience and wanted to be involved in more of them. As a result, the medication management simulations have been embedded in the skills modules. However, the planning of these sessions takes time and energy and with more time being allocated to ‘business’ rather than the actual practice of teaching (Jarvis, 2018), the time allocated for preparation of learning and teaching activities is threatened. The creation and maintenance of case scenarios also require planning and resource allocation, while the analysis of evaluation data can add to lecturers' regular workload. However, feedback from students is essential and can help determine future revisions.

There is growing partnership and collaboration across university departments to develop more inter-professional medication management simulations with post-registration students undertaking the prescribing course. This would require the involvement of pharmacists, qualified nurses and doctors to take part in the medication management simulations. There are plans to provide better moulage and props to further enhance the ‘reality’ expressed in student feedback.

Conclusion

This article has used simulation to engage students early in safe practice in medication management. It highlighted how students can learn through being put into ‘real-life’ situations that challenge them to think and provide them with opportunities to lead. In addition, the experience has made students realise how they can provide safe practice for themselves and their patients.

The medication management simulation was powerful in creating future practitioners who are advocating safer medication management practices alongside the advancement of recognising nurses' position as autonomous practitioners. This serves to provide a clinical service to all patients who are vulnerable and in need of medication.

Key Points

• The administration of medications can save lives, but is often complex and mistakes can occur
• Medication errors can be reduced by encouraging safe practice
• Safe practice in medication management should start early in nurse education
• A way to potentially reduce medication errors can be by setting up simulated drug rounds