Author: Donna E. McCabe, DNP, APRN-BC, GNP
Title: Clinical Assistant Professor
Institution: New York University Meyers College of Nursing
Coauthors: Emerson Ea
1) Knowledge-Examine human factors and other basic safety design principles as well as commonly used unsafe practices.
2) Skill-Participate appropriately in analyzing errors and designing system improvements.
3) Attitudes-Appreciate the cognitive and physical limits of human performance. Value own role in preventing errors
Medication dosage calculation competencies has been a mandatory rite of passage through nursing school as well as practice. It is difficult to argue the importance of examining this competency in nurses who are most often the professional administering the medications and serve with the patient and family as the last chance for error prevention. Despite the enormity of the safety implications surrounding medication dosing and administration there is little evidence to guide us in best practices for teaching. Most schools require successful completion of a standard exam with a set score, and not all require a 100%.
This strategy to improve acquisition of safety KSAs with medication dosage calculation has an added element of remediation and reflection. Students first complete a comprehensive on-line learning module to prepare for the test. On-line courses are available for purchase associated with commercial textbooks, can be designed by faculty, and some are available free via internet. A few examples can be found here and here. Many pharmacology texts and resources also have dosage calculation and medication administration content. Students takes “practice” tests throughout the module. Prior to being permitted to administer medications in the clinical setting students must compete a 10 question medication administration/dosage test with 100% success. Students have three attempts to achieve this competency.
Students who are not successful on the first attempt are required to meet with the instructor in small groups to review the test to remediate and reflect on their errors. The guide for reflection includes;
1) How did the error occur? Was it a calculation error (math error or formula error)? Was it a “silly” error (not checking or going to fast)?
2) Consider if this error occurred in practice, describe how you would handle the issue?
3) How would you monitor the patient if this error occurred?
4) How would you feel if you were involved in this error in clinical practice? Where would you turn for support?
5) What steps could you or would you take to prevent an error of this nature from occurring again? Are you familiar with strategies used in healthcare facilities to prevent medication errors? If so, please describe the strategies.
Students complete a written reflection while in the room with the instructor and small group and are encouraged to share what they learned and how they felt in the remediation and reflection.
Remediation and reflection are two educational models. Reflection has a great deal of evidence to support its effectiveness in fostering critical thinking in nursing education. Remediation, the act of correcting, is gaining momentum in the nursing education field. Pairing both of these models has proven to be anecdotally successful in enhancing medication dosage calculation learning. Students reported enjoying the process of reviewing and remediating their error. The comments bring forward a broad range of feelings and questions, likely not those raised by the straight forward dosage calculation exam.
Examples of student response:
• “My patient would have been fluid overloaded and short of breath.”
• “I could have killed my patient.”
• “The patient would have needed a pacemaker.”
• “I would feel terrible if I made this error. Do nurses have to apologize?”
• “I didn’t ever know what carvedilol was while I was taking the test?”
• “Can nurses split a pill in half”
• “What if I didn’t even realize I made an error? Who double checks me in real life.”
The shared reflection among the small group of students is powerful. The instructor is able to set the tone for open discussion and provide a safe environment. Students were honest and humbled by ease of possible human error. Given the success of the remediation and reflection sessions, small group sessions will be held in the future for all students regardless of passing at 100%.
Culleiton, A. L. (2009). Remediation: A closer look in an educational context.Teaching and Learning in Nursing, 4(1), 22-27.