Simulated scenarios help nursing students practise strategies to reduce medication errors

A few years ago, UCalgary Nursing senior instructor Kathleen Davidson, RN, MN, was developing an article (with fellow nursing instructor Kara Sealock and then-student Wai Yin Mak) about nursing students with ADHD and managing distractions in the workplace.   

“It became apparent to me that all nursing students, to a greater or lesser degree, struggle with distraction in the clinical environment,” Davidson says now. And so began her research to uncover a method to help students hone their selective attention skills for managing in often chaotic clinical situations.

That research has resulted in a recently published open-access article, Adapting a Distraction and Interruption Simulation for Safe Medication Preparation: An International Collaboration, in Clinical Simulation in Nursing, Volume 65, April 2022. 

Nurse distractions and interruptions are leading causes of medication errors in nursing practice, with medication preparation being the most-interrupted activity.

“It is students and novice nurses who are most likely to make a medication error,” explains Davidson, “often because they haven’t honed those selective attention skills.” Interruptions may include self-distraction, events close by, patients, other health-care providers, phone calls and texts. 

“Lots of nursing students believe that distractions and interruptions won’t affect their focus, which can be very dangerous. But we don’t have many evidence-informed strategies for how we can teach maintenance of safety with inevitable distractions,” Davidson says.  

Davidson was intrigued by a simulation created by nursing faculty at Ball State University in Indiana, led by Dr. Cindy Thomas, RN, EdD, in which groups of 10 students entered a lab, put on headphones with a recorded hospital soundtrack at a set volume and completed the preparation of 10 medications.

Faculty and others entered and exited the lab while carrying on conversations and asking the students questions. At the end of the eight-minute simulation, students self-checked the medications they had prepared and discovered they consistently made errors including dosage miscalculations, failing to withhold medications due to patient allergies, or not completing the medication preparation.  

In collaboration with Thomas, Davidson and her UCalgary Nursing team (Carla Ferreira, Pat Morgan and Lorelli Nowell) adapted and piloted the U.S. simulation with 18 Canadian nursing students in 2019.

Some of the changes from the U.S. simulation included two students sharing a medication cart located in a narrow, crowded hallway outside the patient rooms, ambient hospital noise plus overhead announcements, intravenous pumps alarming, patients’ call bells ringing, and interruptions by family members. 

Students experienced their first interruption, from a family member, approximately three minutes into preparing medications. Three minutes later, students were interrupted again by an RN colleague and approximately one minute later, the final interruption was an overhead announcement.

At the conclusion of the simulation, students self-evaluated their prepared medications for accuracy and, in a facilitated debrief, reflected on their experience with the simulation. While never directly asked, some voluntarily spoke about making medication errors and having near-miss events during the simulation.

Students consistently indicated the exercise accurately reflected clinical conditions and allowed them to critique their personal responses to distractions and interruptions. Strategies that students used during the simulation were shared among group members along with ideas for coping with distractions and interruptions in practice.  

Reducing medication errors and improving patient safety are central concerns of the nursing profession on both sides of the Canada-U.S. border and have led to an international research project to discover how this simulation may enable students to develop strategies for maintaining safe medication practices in highly interruptive clinical environments. 

Safely exposing senior nursing students to medication errors and near-miss events through simulation is one way to help address this ongoing issue.

“Reflecting on and refining their personal strategies to maintain focus will hopefully sensitize students/novice nurses about their role in avoiding interrupting their colleagues and the myth of multi-tasking,”  says Davidson.