Learning From Simulation-Based Medication EventReporting: A Mixed Methods Analysis

Abstract

Background: Errors committed during the course of delivering care represent a significant threat to patient safety. Nurse educators are in a unique position to effect change in patient safety, but more opportunities for learning from and reporting errors are needed to realize this goal. Method: This study used the convergent parallel design and followed three cohorts of students longitudinally. As part of the simulation program, students were asked to report any adverse events committed or observed during simulation encounters. The reported medication events were analyzed using chi-square analysis and content analysis. Results: A decreasing trend of reported medication events across courses was found. Chi-square analysis showed statistically significant differences in the categories of wrong dose, wrong patient, failing to ID the patient, communication breakdown, medication handling, knowledge, and personal distraction. Themes identified via content analysis of the open-ended questions included needing to improve communication; double checking orders, dosages, and patient identifiers; needing to gain more medical knowledge; deficiencies in assessment skills; poor focus; distraction; and nervousness. Conclusion: The findings uncover a domain of patient safety that has not been fully explored. The results provide a deeper insight into how students acquire knowledge from making errors and how they incorporate and reflect on lessons learned as they gain knowledge and skills.