Avoiding Medication Errors 8/29/09 1:53 PM

Avoiding Medication Errors: Examining the Policy for Testing the Proficiency of Student Nurses

Theresa Pietsch (2005)

RETURN
edited 10/16/08

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?

Literature review
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

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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.

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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.

Medication Administration Policy

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.

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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.

Procedure:

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.

Findings and Arguments: What are the issues?

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.

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Do reasonable people differ on the answer? How does your research support one side
or another?
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.

Assumptions
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.

What is the structure of the argument?

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

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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.

References
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.

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