Learning From Simulation-Based Medication Event Reporting: A Mixed Methods Analysis

• The system allows student to experience an aspect of “just culture.”
• This study uncovered the effects of learning on reported medication adverse events.
• Trends followed a trajectory mirroring a “novice to expert” pattern.
• A novel use of simulation to cultivate the positive habit of being transparent.
• Offers deliberate practice opportunities in reporting adverse events.

BackgroundErrors 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.MethodThis 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.ResultsA 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.ConclusionThe 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.