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A medication dosage simulation strategy to improve patient safety

By: Nadine M. Marchi, DNP, MSN, RN, CRRN, CNE, CHSE; Elizabeth Zimmermann, DNP, MSN, RN, CHSE; Connie S. Kelling, WHNP, MSN, RN; Shannon Wong, MSN, RN, CPNP; and Kathleen M Juniper, MSN, RN, WHNP-BC

Simulation boosts skills and encourages active learning. 


  • Traditional medication administration dosage testing can be time-consuming, costly, and lack elements of active learning. 
  • Simulation in nurse education provides authentic clinical situations in a safe environment.  
  • A medication dosage simulation project has shown positive outcomes. 

Medication dosage calculation proficiency is critical to safe nursing care. In most clinical and academic settings, nurses must demonstrate 100% accuracy with medication dosage administration. The time required to develop, administer, grade, remediate, and re-examine a valid medication calculation exam is costly. In addition, completing paperandpencil math exams doesn’t promote active learning. Incorporating active learning strategies can enhance student engagement, promote deep learning, and translate theory to practice.  

Evidence shows that simulation education provides authentic clinical situations in a safe environment and is a link to safe practice. The National Council of State Boards of Nursing (NCSBN) conducted a national multisite study with 666 students to examine simulation use in prelicensure nursing programs. The study was conducted in three phases: simulation usage, student outcomes based on percentage of simulation vs. clinical time, and assessment of graduates as new RNs. The study supported the effectiveness of simulation to gauge competency of prelicensure nurses as they moved into the RN role. 

Because simulation has been shown to be an effective teaching tool, we decided to use it to improve patient safety related to medication dosages. We followed simulation guidelines from the International Nursing Association for Clinical Simulation (INACSL) and the INACSL Standards of Best Practice: SimulationSM and used the Quality and Safety Education for Nursing competencies to guide our work. Here is an overview of the project and its outcomes.  

Case study 

Nursing educators met to discuss the ineffectiveness of pediatric and obstetric medication dosage administration courses. The team discussed their frustration with the requirement to repeatedly administer exams with dosage calculations until students achieve a 100% so they can participate in the clinical experience. In addition, students evaluated the experience poorly and described the process as a highanxiety event. 

The team of educators decided to implement medication dosage administration simulation stations with competency assessments. Each simulation station is attended by a faculty member familiar with the content, and the student’s calculations are verified before he or she moves to the next station. After completing all of the stations, each student takes a medication dosage calculation exam and participates in a reflection exercise. (See Reflecting.)


The reflection questions were designed to help students consider the importance of medication calculation and administration. The first two questions are used for students who did not achieve 100% on the exam.

  1. If you made an error, review the calculation and consider how your error occurred.
  2. List three steps you must take to relearn and recalculate.

Now that you’ve completed questions 1 and 2, return to the station for remediation. When you have accomplished 100% accurate remediation, complete a second medication dosage calculation exam. Retest only on the area(s) where you didn’t achieve 100%.

The second two questions are used for those who achieved 100% on the exam.

  1. What reaction would you expect to have if you made a medication error during your clinical practice and why?
  2. List three steps you must take to correct any medication error in clinical practice.

If the student doesn’t achieve 100% on the exam, he or she returns to the appropriate station or stations to remediate the concept and practice dosage calculations. The student is then retested on the same day in the area where an error was made. If a student doesn’t achieve 100% after remediation, a second round of remediation and retesting occurs. 

Preimplementation planning and challenges 

Before implementing the simulation, several planning steps were completed, including notifying the program directors and course faculty of the change. Most accepted the new format, but one faculty member was concerned that the simulations and remediation weren’t rigorous enough. She felt that the repetitive math testing should continue with no simulations or remediation. When the process was more fully explained and the faculty member understood that all students would still need to achieve 100% on the exam, she agreed to the new format. She was invited to join the team and participate in the stations during the lab. 

To ensure all students could attend the simulation lab, some scheduling changes were required. One team member worked with a faculty member to switch the time of a class to incorporate the lab into the student schedule before the beginning of the clinical experience. Another team member divided the students into groups of eight and plotted the flow of each 90-minute lab session with four practice stations and one testing station.  

Additional rooms and space were found and reserved, and time was established in the course schedule and in the simulation center for the new program. In addition, more supplies were purchased for the lab, faculty were identified to attend the simulation stations, a plan was created for setting up and dismantling the stations, student guidelines were developed, and a post activity evaluation and student reflection were created 

To prepare students for the simulation, they were provided with readings, an online module with narration, and practice problems. Four different tests were developed to prevent students from sharing information with the next group.  

Planning for the simulation lab began in September 2017, organization occurred in October, and supplies were ordered in December. In January 2018, the new strategy was implemented with the BSN students.   

Objectives and outcomes 

The objectives for medication dosage administration lab already existed for the pediatric/obstetrics course, but they were revised to include the new simulation format  

Objective 1. Students will calculate accurate medication dosages and prepare medications safely by the end of the simulation lab. 

  • Measurable goal: All students enrolled in the pediatric/obstetrics course will successfully complete the revised medication dosage administration simulation lab. 
  • Results: A total of 99 students successfully completed the medication dosage administration simulation lab. Some students had to remediate and complete the second math test on the same day as the lab.  

Objective 2. Students will demonstrate safe and accurate psychomotor skills by the end of the medication dosage administration simulation lab. 

  • Measurable goal: All students will perform math calculations and medication dosage administration at each lab station and demonstrate competency. 
  • Results: All students practiced psychomotor and safety skills related to medication dosage preparation, medication administration, and math calculation at each lab station. A faculty member at each station checked students’ competencies before they proceeded to the next station. 

Objective 3. Students will complete the medication administration dosage exam with 100% accuracy. 

  • Measurable goal: All students will complete the medication dosage exam with 100% accuracy on the first or second attempt on the same day as the scheduled lab. 
  • Results: On the first attempt at the exam after the simulation activity, 45% of students achieved 100% accuracy. The remaining students passed the medication dosage exam on the second attempt after remediation at the appropriate station. All students started their clinical experience on time.  

Objective 4. Students will complete a reflection about safe medication administration at the end of the simulation lab.  

  • Measurable goal: All students will complete the reflection. 
  • Results: All students completed a reflection and then were dismissed from the lab. Students commented that the reflection made them review their performance and realize the importance of safe medication administration.  

Objective 5. Students will complete an online evaluation one day after the medication dosage administration simulation lab. 

  • Measurable goal: All students will complete the online evaluation of the lab. 
  • Results: The online evaluation was completed by 50% of the students. The data were analyzed and improvements made for the next lab. Faculty also completed an evaluation within 1 week.  

Simulation day 

To make the simulation as realistic as possible, equipment and scenarios were created to be similar to a real-life hospital setting. Each skill station was equipped with hand sanitizer, gloves, alcohol wipes, sharps containers, and calculators. A pediatric or obstetric faculty member was at each station to answer questions and monitor and verify accurate skill completion. 

Groups of eight students each rotated through the lab at scheduled times. They were given a 90-minute time limit, with 15 minutes for each station (an extra 15 minutes was available if the group needed it). As students entered the room, they signed in and took a folder with instructions and a math problem for each station. To ensure all students had completed the prelab activities, each signed a statement signifying they had viewed the online module and brought completed practice problems to the lab for admission. 

At each station (fluid maintenance and urine output, safe dosing, reconstitution, and drip rate), students calculated the correct dose and practiced preparing and administering the medication. The final exam and reflection were administered in a separate, quiet room next to the lab. Students had 15 minutes to complete the exam. 

Four math exams were developed by the team and distributed randomly to students when they entered the final station. The exams consisted of math problems similar to those completed at each station. If a student scored 100% on the exam, he or she completed the two reflection questions. If a student didn’t score 100%, he or she returned to the simulation area and remediated at the stations related to the exam errors. The student then returned to the testing room to retake the portions of the exam related to the errors and completed the reflection questions. Upon completion, the student was considered ready to administer medications in the clinical setting 

Next steps

The new medication dosage administration simulation lab has been completed with two groups of students. Evaluations have been positive, with areas of improvement suggested by students and instructors. (See Simulation evaluation.)

Simulation evaluation

Students and instructors were asked to complete a simulation lab evaluation.

Student results and comments

  • Was the process of preparing for the day clear? Yes: 91%
  • Was the process during the day clear? Yes: 91%
  • Did your knowledge of medication safety and delivery improve? Yes: 95%
  • How much do you value medication safety? 78% valued it more than before the simulation lab
  • Was safety day a positive experience? Yes: 87%
  • “Amazing.
  • Thank you!”
  • “Very helpful and fun.”
  • “Tell us up front what the objectives are.”
  • “Waiting at stations is boring.”
  • “Conducive to the way we learn.”
  • “Relaxed environment and patient faculty.”
  • “Executed really well!”

Instructor comments

  • Well organized but need to revise practice math problems to better reflect actual dosages.
  • One station reviewing a patient safety poster can be included in the pre simulation presentation.
  • Realistic supplies are needed and worked well.
  • Pre simulation assignment should be better explained.

At the end of the lab, students are ready to administer medications in clinical, and they don’t have to undergo repetitive math testing. The new process is more efficient for students and faculty. The working group of nurse educators continues to make improvements with the simulation. For example, they’ve arranged for smaller groups and clarified the pre simulation instructions. 

This learning strategy can be used with prelicensure students, graduate nurses, preceptees, and staff nurses in a variety of specialties. In all cases, patient safety related to medication dosage administration and calculation can be enhanced. 

Nadine M. Marchi is a clinical assistant professor at The George Washington University School of Nursing in Ashburn, Virginia. At Case Western Reserve Frances Payne Bolton School of Nursing in Cleveland, Ohio, Elizabeth Zimmermann is an assistant professor, and Connie S. Kelling, Shannon Wong, and Kathleen M. Juniper are nursing instructors.  

Selected references

Benner P. Curricular and pedagogical implications for the Carnegie Study, educating nurses: A call for radical transformation. Asian Nurs Res. 2015;9(1):1-6.  

Cant RP, Cooper SJ. The value of simulation-based learning in pre-licensure nurse education: A state-of-the-art review and meta-analysis. Nurse Educ Pract. 2017;27:45-62 

Huston CL, Phillips B, Jeffries P, et al. The academicpractice gap: Strategies for an enduring problem. Nurs Forum. 2018;53(1):27-34. 

Jeffries PR, Dreifuerst KT, Kardong-Edgren S, Hayden J. Faculty development when initiating simulation programs: Lessons learned from the National Simulation Study. J Nurs Regul. 2015;5(4):17-23.  

Lindell A. Enhancing medication safety teaching through remediation and reflection. QSEN Institute. November 1, 2016.  

Miraglia R, Asselin ME. Reflection as an educational strategy in nursing professional development: An integrative review. J Nurses Prof Dev. 2015;31(2):62-72. 


1 Comment.

  • Sandra Gupton, RN
    September 11, 2019 9:49 pm

    I find this tool to be very useful and should be incorporated into the healthcare setting for nurses education day to keep everyone abreast on how important it is for patient safety when it comes to the delivery of medication. Different nursing departments lose their skills if they are not giving medications routinely (i.e., psych. unit, and the ortho rehab., versus the ICU/CCU, open-heart unit, neuro-intensive care, surgical intensive care). Thank you for the article.

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