According to the Agency for Healthcare Research and Quality (2019), 5% of hospitalized patients experience an adverse event from a medication error, making this one of the most common types of errors. At the same time, studies have shown that only 23% of new RNs are meeting entry-level expectations for clinical judgement (Kavanagh & Szweda, 2017). The literature has also shown that 49% to 53% of new nurses are making medication errors (Zimmerman & House, 2016), and the Advisory Board Company found that “only 41% of new nurses were proficient in medication administration and only 28% had knowledge of pharmacologic implications” (as cited in Zimmerman & House, 2016, p. 49).
Nurse residency programs have been greatly increasing in health facilities for multiple reasons. New RNs experience job stress and dissatisfaction during their first year of employment (Perron et al., 2019). These residency programs focus on retention and increasing job satisfaction among new RNs by providing strong support and mentorship throughout the first year (Perron et al., 2019). In regard to medication administration, nurses have a low understanding of pharmacological implications (Escrivá Gracia et al., 2019), and it has also been found that new RNs have acknowledged the need to increase their medication administration knowledge and knowledge of pharmacologic implications (Lim & Honey, 2017).
Because of theory-to-practice knowledge gaps, it is recommended that simulation be incorporated into nurse residency programs. Simulation has been shown to be improve clinical competency, improve confidence and self-efficacy, and improve safety (Alt-Gehrman, 2019). The literature has also demonstrated that simulation can lead to significantly fewer medication errors among nursing students (Alt-Gehrman, 2019).
Simulation can be one way to help support new RNs' medication administration knowledge and safety. The purpose of this research project was to increase knowledge, skill, and competence of medication administration among new RNs in a nurse residency program. This research project also aimed to answer this question: In new RNs, what is the effect of simulation, in comparison with didactic classes only, on safe medication administration knowledge and skill?
The study sample consisted of new RNs with less than 1 year of nursing experience. The participants were recruited from two residency cohorts throughout the south region of a large health care system in the Midwest. These participants included nurses from three different hospitals and various adult inpatient units (i.e., medical–surgical, telemetry, intensive care unit). The participants scheduled to attend the medication administration residency curriculum content during the implementation time frame were chosen for this study. Ethical approval was granted for this research study by the agency's institutional review board, and informed consent was obtained from all participants. No identifiers were collected during testing or simulation. A total of 54 new RNs participated in this study.
This study implemented a mixed-methods, quasi-experimental, nonequivalent control group posttest design to determine if simulation would have a positive impact on medication administration knowledge of new RNs. A medication administration knowledge test was created to align with system-wide hospital policies and procedures of medication administration. The test contained 16 multiple choice/select all that apply questions, four survey questions about perceptions of medication errors, four open-ended questions about how participants will change their practice to provide safe medication administration at the bedside, and one overall satisfaction question. Simulation performance was measured using a modified Medication Administration Safety Assessment Tool developed by Goodstone and Goodstone (2013). Permission was obtained from the creators to use and modify the tool. The simulation objectives included performing the five rights of medication administration, retiming missed doses per hospital policy, using appropriate resources to verify a new medication, and identifying an order entry error. These objectives were chosen for the scenario because the literature has determined that the five rights are the best way to prevent errors, and wrong-time errors are the most common type of error (Agency for Healthcare Research and Quality, 2019; Blignaut et al., 2017).
The 25 participants in the control group received the program's medication administration didactic content and then completed the medication administration posttest. The 29 participants in the intervention group completed the medication administration didactic content, completed a simulation in small groups, and then completed the medication administration posttest. Prior to simulation, the intervention group received a prebrief presentation discussing simulation logistics and a room orientation.
The simulation experience took this form: The participants were brought into the simulation room in groups of four to six. Two volunteers in the group were taken to the patient room and were provided a change-of-shift report. They were to take care of a patient who was no longer “nothing by mouth” for a surgery and the patient wanted medications prior to eating. As the two participants completed the simulation, all other members of the group watched a live stream of the simulation in the debriefing room. Immediately following the scenario, a debriefing session was completed with all participants in the group. Debrief lasted at least double the time of the simulation, and the PEARLS Healthcare Debriefing Tool by Bajaj et al. (2017) was used to guide the session. Debriefing allowed participants to reflect on their initial reactions with the scenario. These initial reactions lead to discussions on specific issues that arose during the scenario and concepts related to decision making and resource utilization.
Although the medication administration posttest scores for the intervention group (M = 11.79, SD = 2.42) were not significantly higher (p = .056) than the posttest scores of the control group (M = 10.56, SD = 2.4) at the p = .05 level, the intervention group's mean posttest scores were slightly higher. There were three individual posttest questions in which the simulation group did significantly better. The simulation group identified which medication was eligible for standard dosing time (p = .034), identified all rights of medication administration per agency policy (p = .004), and identified what to verify before administering an oral narcotic (p = .025).
During simulation performance, all groups completed the five rights of medication administration and retimed the missed doses correctly per policy. Interestingly, all groups made the same error in relation to the order entry error. An intravenous push medication was ordered as 10 mg, when 1 mg was actually within the safe dose range. Each group questioned the volume required to push based on the provided vial's concentration, but no group questioned the wrong dose or used resources to look up safe dose ranges for the unfamiliar medication. It was discovered during debriefing that safe dose ranges were not regularly referenced prior to administering new or unfamiliar medications. In this study, the use of simulation helped to identify this consistent knowledge gap among this sample of new RNs.
The survey questions identified the perceived reasons for medication errors and why medication errors are not reported among the participants (Table 1). Wrong-time errors (51.9%) and omitting medications (23.2%) were identified as the most common type of errors, which is consistent with the literature.
Multiple themes were identified from the open-ended test questions. “The 50% Rule” policy was identified by half of the participants as the most helpful aspect of the session because they were completely unaware of this policy. This policy states that if the time between doses is less than 50% of the dosing interval, the dose is given as scheduled; times greater than 50% will be skipped, and the next dose given at the next originally scheduled time (Frangella, 2018). Eighty percent of participants stated they plan to share this policy with their colleagues.
Approximately one quarter (24.1%) of the intervention group identified simulation as the most helpful aspect of the session. Participants (40.7%) also discussed distractions stating that “going over the many ways medication errors occur” and “understanding multiple ways [medication] errors can happen and how to avoid them” were the most helpful aspects of the session. Finally, participants identified a desire for more medication administration education to be provided. Participants stated, “Have this presentation earlier in the residency program,” and “I think this should be taught earlier in the new grad program.” Others recommended, “Review the medication administration policies during orientation,” and “New nurses should have a standard course they go through that teaches expectations for med pass. Relying on preceptors leaves everyone with only half the info they need.” Although not significant (p = .056), the intervention group was slightly more satisfied with their learning experience than the control group.
Some limitations of this study include the small sample size, nonequivalent groups, and no randomization of groups. This study was designed to be a small-scale research pilot, and it would be beneficial to complete this study again with randomizing participants and using a larger sample size to determine if the same results would occur.
Simulation slightly increased medication administration knowledge posttests scores, and simulation participants were more satisfied with their learning experience. The simulation group answered more questions correctly related to timing of medications, the rights of medication administration, and identifying safety measures prior to administering high-alert medications. This may possibly be related to the experiential learning that simulating provided, which reinforced concepts learned during the didactic component. Simulation also identified a consistent knowledge gap in relation to medication volume to be administered versus correct dosage. New RNs also identified a need for more medication administration education earlier in their residency program.
This study also helped to identify ways the hospital system's nursing residency program could be adapted to assist in safer medication administration practices. It was recommended to provide medication administration education early in orientation and in the residency program, including specific discussions on safe dose ranges and clarification of what actually constitutes a medication error. It was also recommended to use case studies, role play, and simulation to practice the retiming of medication using the “50% Rule” early in nursing orientation.
Further research also needs to be done to determine how effective simulation is for new RNs, to identify further gaps in medication administration knowledge, and to see how a medication administration simulation would affect medication errors in practice among new RNs over time. Although this study was small in scale, it demonstrates the benefits that simulation can have among new RNs and medication administration safety.
- Agency for Healthcare Research and Quality. (2019). Medication errors. Patient safety network. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
- Alt-Gehrman, P. (2019). Nursing simulation and transfer of knowledge in undergraduate nursing programs: A literature review. Nursing Education Perspectives, 40(2), 95–98 doi:10.1097/01.NEP.0000000000000398 [CrossRef] PMID:30148759
- Bajaj, K., Meguerdichian, M., Thoma, B., Huang, S., Eppich, W. & Cheng, A. (2017). The PEARLS Healthcare Debriefing Tool. https://debrief2learn.org/wp-content/uploads/2017/12/PEARLS-Small-Poster-8.5x11-PDF-EN.pdf
- Blignaut, A. J., Coetzee, S. K., Klopper, H. C. & Ellis, S. M. (2017). Medication administration errors and related deviations from safe practice: An observational study. Journal of Clinical Nursing, 26(21–11), 3610–3623 doi:10.1111/jocn.13732 [CrossRef]
- Escrivá Gracia, J., Brage Serrano, R. & Fernández Garrido, J. (2019). Medication errors and drug knowledge gaps among critical-care nurses: A mixed multi-method study. BMC Health Services Research, 19(1), Article 640. doi:10.1186/s12913-019-4481-7 [CrossRef] PMID:31492188
- Frangella, G. (2018). Medication administration system policy and procedure. Unpublished internal document.
- Goodstone, L. & Goodstone, M. S. (2013). Use of simulation to develop a medication administration safety assessment tool. Clinical Simulation in Nursing, 9, e609–e615 doi:10.1016/j.ecns.2013.04.017 [CrossRef]
- Kavanagh, J. M. & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses' clinical reasoning. Nursing Education Perspectives, 38(2), 57–62 doi:10.1097/01.NEP.0000000000000112 [CrossRef] PMID:29194297
- Lim, A. G. & Honey, M. L. (2017). New graduate nurses' knowledge and skills in medication management: Implications for clinical settings. The Journal of Continuing Education in Nursing, 48(6), 276–281 doi:10.3928/00220124-20170517-09 [CrossRef]
- Perron, T., Gascoyne, M., Kallakavumkal, T. K., Kelly, M. & Demagistris, N. (2019). Effectiveness of nurse residency programs. Journal of Nursing Practice Applications & Reviews of Research, 9(2), 48–52 doi:10.13178/jnparr.2019.09.02.0908 [CrossRef]
- Zimmerman, D. M. & House, P. (2016). Medication safety: Simulation education for new RNs promises an excellent return on investment. Nursing Economic$, 34(1), 49–51 https://www.nursingeconomics.net/necfiles/2016/JF16/49.pdf PMID:27055312
|Survey Question||Response Rate (%)|
|Top three reasons why new RNs think medication errors occur|
| Communication errors||36|
| Inadequate staffing levels||33.6|
|Top three reasons why new RNs are not reporting medication errors|
| Fear of retribution||73.3|
| Believing others will think they are incompetent||62.6|
| Not realizing an error even occurred||47.1|