Avoiding Medication Errors:
Examining the Policy for Testing the Proficiency of Student Nurses
Theresa Pietsch (2005)
Entry-level nursing curriculum includes theory, principles, and technical skills that span the stages of human development. Upon graduation, nursing students have successfully passed courses in sciences, humanities, and social sciences regardless of the type of education degree granted for entry level nursing practice. Students have the option to enter into nursing practice from three divergent levels of schooling, 1) diploma, 2) associate or 3) baccalaureate degree, yet all receive identical licensure as registered nurses.
Upon completion of any one of the three types of nursing programs, graduates must successfully pass the National Council of Licensing Examinations for Registered Nurses (NCLEX-RN®)administered by the National Council of State Boards of Nurses. Hence, all nursing curriculum must address the national expectations and standards for minimal entry into practice. If graduates do not meet the NCLEX-RN® cut-off score, graduate nurses may not practice until successful re-testing occurs and state licensure is granted by the individual State Board of Nursing.
NCLEX-RN® failure rates have tremendous impact on nursing schools. Accreditation bodies may place schools on provisional status, or revoke accreditation, if the aggregate scores from graduating classes fall below a pre-established pass rate. Therefore, educators have tremendous pressure to develop and implement curriculum that meets national nursing standards and have successful test-takers of the NCLEX-RN® examination.
In 2001, the academic pressure significantly increased in nursing, after the Institute of Medicine released a report documenting over seven thousand deaths/year from medication errors and reform efforts were flawed given the convoluted systems (Institute of Medicine, 2005). The public and professional outcry from this report pressured most nursing programs to revamp teaching strategies and revise standards for medication administration. Many nursing schools adopted strategies to assess medication calculation proficiency every semester. Increased assessments created the need for nursing programs to initiate or revamp existing policies.
What were the consequences for failure of medication calculation tests? Should 100% correct response be the standard for medication calculation tests? Or, was an 80% pass rate more acceptable in an environment for student nurses?
The debate on preventing medication errors made national public headlines after the National Institute of Medicine released their landmark findings in two separate reports titled; To Err is Human, Building a Safer Health System and Crossing the Quality Chasm: The IOM Health Care Quality Initiative (Institute of Medicine, 2005). These reports identified real and potential adverse outcomes that occurred yearly from medication errors. Following this report, medication errors were then linked with flawed healthcare systems within practice settings. However, regardless of the system issues, the attention quickly shifted to mathematical competence of professional nurses. If professional nurses were targeted, there was a natural pathway paved toward targeting entry-level nursing education about medication administration. As a result, nursing faculty had additional pressure beyond the NCLEX-RN ® examination, yielding tremendous pressure to stop medication errors.
According to Johnson and Johnson (2002), the learning process for medication calculations has been problematic for nursing faculty and students for years. The problems that occur were multi-faceted and attributed to an array of factors that included students' limited basic mathematic skills, to disagreement among the faculty as to best teaching.
Johnson and Johnson (2002) suggested a unique model to address four components which the authors identified as essential for calculation of medication dosages. The four processes, 1) compute, 2) convert, 3) conceptualize, and 4) critically evaluate, were incorporated into a singular comprehensive teaching model for students. Scaffolding, a learning process whereby students build on previously learned material, was considered to be the underpinnings of the model. By building a foundation specifically for medication calculations, the authors identified greater collaboration between faculty and students.
Rice and Bell (2005) also cited problems in practice with substandard abilities of nurses to calculate medication dosages. Calculation of medications was an essential step in safe medication administration, and was necessary to safeguard patients. The authors referenced the American Society of Health-Systems Pharmacist system which identified nine categories that contribute to medication errors.
Rice and Bell (2005) also discussed nursing students as classified poor performers in mathematics, expended high anxiety levels when dealing with calculations, and exposed to inconsistent teaching strategies in medication calculations. Mathematical formulas have been identified as problematic due to misapplication of formulas or miscalculations. Best teaching practices have been elusive and results for nursing students were dismal.
Drawing on previous skills taught in Chemistry courses, Rice and Bell (2005) studied the application of dimensional analysis as an alternative learning strategy for medication calculations. Working from the assumption that students successfully completed science courses, the authors studied a total of 30 nursing students over two semesters. The authors concluded the learning strategy, dimensional analysis, was successful in improving conceptual skills, thereby reducing the number of incorrect responses to test items.
Elliott and Joyce (2005) discussed the need to develop calculation skills over time, and not assume the mathematical skills have been previously taught to students. The development of these essential skills were not captured in one semester, instead these skills were built across all nursing courses. Elliott and Joyce suggested as content material became more complex over time, the pass rate for medication calculation tests should also become more difficult. Hence, the authors suggested building medication calculation mastery over a period of time to successfully reach medication calculation proficiency.
The question of "What to do with the student who fails?" was addressed by Elliott and Joyce (2005). The provision of re-takes for failed tests was built into the curriculum with remedial assistance offered between each failed tests. A total of four tests were permitted before a decision to academically remove the 'failed student' from the course. The authors had 100% successful pass rates for medication calculations examinations when multiple re-tests and remediation plans were offered. Of the 130 students enrolled in this nursing program, no student was academically removed from course work due to non-proficiencies in medication calculations.
The results of Elliott and Joyce's (2005) research with 130 students not only supported the concept of on-going assessment of medication calculation skills, but additionally, the role of faculty to develop medication skills over a four-year curriculum. Nursing students would then advance from simple medication problems to highly technical and complex medication calculations. Elliott and Joyce recognized mathematical skills, may not necessarily be as simple as a review process, but suggested these skills be developed overtime in nursing curriculum.
Although much discussion in the literature focused on the nurses' role in creating medication errors, with particular emphasis on mathematical skills of nurses, there were other significant contributing factors that influenced the risk factor of medication errors. Because medication administration does not occur in a vacuum between patient and nurse, many healthcare professionals have begun to discuss the multitude of system opportunities to misread, misinterpret, and misadmisister medications.
Koppel et al. (2005) discussed the medication error risks generated from physician order entry. Physician order entry was described as computer generated physician order, whereby the physician can directly enter the order into the database. The receiving staff would then access the computer written order to complete the task of medication administration. The goal of computerized physician entry order systems were to lower the risk of medication errors by improving legibility, standardizing high risk medication orders, and linking pertinent clinical data to the medication administration process. The results of this quantitative and qualitative study from a large tertiary teaching-hospital indicated the computerized physician order entry system impacted on 22 types of medication error risks. The risk factors were not lowered for the identified 22 medications, but instead the computerized system facilitated the risk factor of the 22 types of medication errors (Koppel et al).
Burke (2005) described the nursing profession's need to broaden horizons for medication administration processes. Under education, barriers to successful and safe medication administration included lack of best practice to teach students the fundamentals of medication administration. More importantly, Burke identified nursing curriculum did not focus on the entire medication administration process. Instead, nursing schools primarily focus on administering, and often disregarded prescribing and dispensing processes.
Burke (2005) identified seven significant barriers to safe medication administration. Lack of interdisciplinary teamwork and efforts, fluctuation in staffing patterns, and use of abbreviations were identified within the seven barriers. Delays in responding to safety concerns and systems flaws within healthcare environments also influenced safe medication administration practice. Burke also identified recent research that has examined the negative impact of nursing staff working over 12 hour shifts or 40 hours per week and the increase risk of medication errors.
In summary, the majority of the literature reviewed examined the teaching strategies of medication administration and mathematical competency of nursing students. However, there was identification within the literature of system flaws that influence risk factors for medication errors.
This medication administration policy and procedure was a revision in 2002 to an existing policy for medication calculation testing of nursing students. The significant revision was to assess nursing students' ability to calculate medication dosages every semester as opposed to sporadically throughout the curriculum. Secondly, failure to meet standards resulted in academic suspension.
Policy:A medication calculation test will be administered to all nursing students before beginning the next nursing theory and clinical course. The test will be an accumulation of previously learned material about medication administration. The examination may consist of all previously learned material applied to the medication administration process. The examination will be required for all students enrolled in all Nursing courses except the entry level course.
1) The medication calculation test will be given on the first day of each semester. In order to pass the test, a grade of 85% must be achieved. The student who fails to attain an 85% will receive remedial work from the faculty leader of the nursing course. The remedial work must be submitted prior to taking the next examination (second test)
2) The second test will be given on the eighth day after the first test. The student who does not achieve an 85% or above on the re-test will be then placed on academic probation. The student will be required to complete additional remediation with an identified faculty member. This remediation must take place within 48 hours of the second failed examination and will include a formal face-to-face meeting with the identified faculty member.
3) A final medication calculation test will be given on the 16th day of the semester. The student must achieve a score of 85% or better to successfully pass. A failure in this test will result in immediate academic suspension for the semester. Prior to registration for readmission for the following semester, the student will be required to submit documentation of completion of a math remediation course. The course must be pre-approved by the Assistant Dean of Academic Affairs. The student will bear the cost of the course and must receive a passing grade of 85% or above.
Medication errors have been linked to severe injuries and countless deaths per year. This issue became national news after the Institutive of Medicine released a landmark report and highlighted the potential of serious injury or even death. Health care providers, politicians, and regulatory agencies began discussing sweeping changes for medication processes and ultimately patient safety. Because nurses are intimately involved in this process, focus turned toward the nursing profession. This outward reflection, in combination with published literature, which documented significant difficulty with basic mathematical skills of nurses, increased pressure for all components of the nursing profession to react.The issue of mathematical competency was not solely linked to nursing students and many hospitals began retesting medication calculation proficiency on an annual basis. At the same time, nursing schools began revising existing policies, and often increased frequency of medication calculation testing and set more stringent parameters for passing scores. As a result, policies and procedures needed to address protocols for nursing students who could not pass this portion of the curriculum.
The nursing literature supported the majority of the revised policy and procedures set forth in this 2002 policy. The strategy and steps for multiple retesting opportunities, as well as structured re-assessments throughout the program was well documented. The need for faculty reaction to mathematical skills, and on-going assessment of calculation skills during school, was also documented in the literature.
However, this policy did not address the development of skills, as discussed in Elliott and Joyce (2005), but rather assumed the student had come equipped with acquired mathematical capabilities. A remediation process was at the core of the proposed policy, while other experts argued skills must be developed and fully acquired throughout the curriculum. Hence, Elliott and Joyce proposed building a foundation, using a scaffolding learning process for medication calculations. These authors structured a teaching platform with learning theory, whereas the other authors did not address pedagogical theory.
More importantly, the literature has documented the significant system issues that may create medication errors. The research of Koppel et al. (2005) addressed the risk factors that can be associated with computerized physician orders. Burke (2005) identified the multitude of system barriers to safe medication practice. More importantly, Burke discussed the need for the nursing profession to address the three components of the medication process – prescribing dispensing, and administering.
The assumption with many nursing schools' arguments for medication calculation policies was the belief that increased frequency of testing will positively impact on medication errors. This implied that medication calculation was significantly more risky than the multitude of other factors that impact on the medication administration process. In addition, there was an assumption that testing processes were equivalent. In general practice, there is often faculty latitude during testing implementation processes and grading practices. Inconsistency of test implementation may result when stakes are high and may result in academic suspension. Additionally, the pass rate for medication tests varies from educational institution to institution. Overall, the assumption that increasing medication calculation testing would positively impact on medication errors presented a narrow and limited perspective.
In essence, the structure of this argument challenged existing nursing education policy on medication calculation tests. While all nursing students should be proficient in medication calculations prior to graduating from school, the profession has not 1) identified best practice to teach this core content 2) incorporated all three components of medication administration into the curriculum and 3) highlighted the system flaws and role of nursing in risk reduction.
Nursing education must look beyond the finite skill of medication calculation and acknowledge system issues that plague most medication errors. Nursing must be experts in evaluating systems embedded within the medication administration process, and educators need to assume leadership with this daunting task. Risk factors could be proactively addressed and ultimately reduce the factors surrounding with medication errors. Hence, nursing faculty must foster critical thinking in risk reduction factors when administering medications and examine the entire continuum of the medication process with students.
In summary, the policy and procedure was at best described as being symbolic to meet the significant public outcry of medication errors. The cost/benefit ratio supported the continuation of the current policy versus 'do nothing'. Given the public's perception and minimal dollar costs to administer, the policy serves a purpose for the stakeholders. While the literature documented the limited mathematical competency of nursing students, repeated exposure to medication calculation may be beneficial to nursing students. However, the question remained "Does the incorporation of semester medication administration tests into nursing curriculum significantly impact on medication errors?"
With two significant processes, prescribing and dispensing, occurring prior to medication administering, the teaching profession has missed a tremendous opportunity to impact on medication errors by looking at the macro system, and challenging students to critically think and evaluate systems and processes involved in medication administration. Hence, refocusing learning on system theory and risk reduction may ultimately reduce medication errors.
Burke, K. G. (2005). Executive summary: The state of the science on safe medication administration symposium. America Journal of Nursing, March (3), 4-9.
Elliott, M., & Joyce, J. (2005). Mapping drug calculation skills in an undergraduate nursing curriculum. Nurse Education in Practice, 5, 225-229.
Institute of Medicine. (n.d.). Crossing the Quality Chasm: The IOM Health Care Quality Initiative. Retrieved November 1, 2005,from http://www.iom.edu/focuson.asp?id=8089
Johnson, S., & Johnson, L. (2002). The 4cs: a model for teaching dosage calculation. Nurse Educator, 27(2), 79-83.
Koppel, R., Metlay, J., Cohen, A., Abaluck, B., Localio, A., Kimmel, S., et al. (2005). Role of computerized physician order entry order entry systems in facilitating medication errors. Journal of American Medical Association, 293, 1197-1202.
Rice, J., & Bell, M. (2005). Using dimensional analysis to improve drug dosage calculation ability. Journal of Nursing Education, 44, 315-318.