Medication Calculation Skills of Registered Nurses

Effectiveness of a computer based medication calculation education and testing programme for nurses

The aim of the study was to evaluate the effect of an on-line, medication calculation education and testing programme. The outcome measures were medication calculation proficiency and self efficacy. This quasi-experimental study involved the administration of questionnaires before and after nurses completed annual medication calculation testing. The study was conducted in two hospitals in south-east Queensland, Australia, which provide a variety of clinical services including obstetrics, paediatrics, ambulatory, mental health, acute and critical care and community services. Participants were registered nurses (RNs) and enrolled nurses with a medication endorsement (EN(Med)) working as clinicians (n=107). Data pertaining to success rate, number of test attempts, self-efficacy, medication calculation error rates and nurses' satisfaction with the programme were collected. Medication calculation scores at first test attempt showed improvement following one year of access to the programme. Two of the self-efficacy subscales improved over time and nurses reported satisfaction with the online programme. Results of this study may facilitate the continuation and expansion of medication calculation and administration education to improve nursing knowledge, inform practise and directly improve patient safety.

Numeracy skills of nursing students

Research has highlighted poor mathematical ability amongst qualified and student nurses. Three major classifications of errors: i)conceptual, ii)arithmetical and iii)computational have been identified. These errors involve being unable to formulate an equation from information given, unable to operate a given equation, or simple arithmetical errors respectively. The objective of this study was to determine if a sample of Australian second year undergraduate nursing students, from the state of Victoria, could accurately calculate drug dosages and perform some basic mathematical calculations that would be required in the workplace. A descriptive survey collecting demographical data, attitudes towards drug calculation performance and basic mathematical and drug calculation questions was administered to the 52 undergraduate nurses who participated in the study. The average score was 56.1%. Interestingly 63.5% of the students denied any drug calculations issues. On average those who completed a minimum of year 12 mathematics, or who had entered the course directly from secondary education achieved scores over 50%. Of all the errors that occurred 36.0% were conceptual, 38.9% were arithmetical and 25.1% were computational. Some Victorian nursing students currently have deficiencies in performing accurate calculations, with both arithmetical and conceptual errors, indicating fundamental flaws in their mathematical understanding and demonstrating an unacceptable level to practice safely.

A literature review of the individual and systems factors that contribute to medication errors in nursing practice

AIM

This paper reports a review of the empirical literature on factors that contribute to medication errors.

BACKGROUND

Medication errors are a significant cause of morbidity and mortality in hospitalized patients. This creates an imperative to reduce medication errors to deliver safe and ethical care to patients.

METHOD

The databases CINAHL, PubMed, Science Direct and Synergy were searched from 1988 to 2007 using the keywords medication errors, medication management, medication reconciliation, medication knowledge and mathematical skills, and reporting medication errors. RESULTS Contributory factors to nursing medication errors are manifold, and include both individual and systems issues. These include medication reconciliation, the types of drug distribution system, the quality of prescriptions, and deviation from procedures including distractions during administration, excessive workloads, and nurse's knowledge of medications.

IMPLICATIONS FOR NURSING MANAGEMENT

It is imperative that managers implement strategies to reduce medication errors including the establishment of reporting mechanisms at international and national levels to include the evaluation and audit of practice at a local level. Systematic approaches to medication reconciliation can also reduce medication error significantly. Promoting consistency between health care professionals as to what constitutes medication error will contribute to increased accuracy and compliance in reporting of medication errors, thereby informing health care policies aimed at reducing the occurrence of medication errors. Acquisition and maintenance of mathematical competency for nurses in practice is an important issue in the prevention of medication error. The health care industry can benefit from learning from other high-risk industries such as aviation in the prevention and management of systems errors.

Nursing students' mathematic calculation skills

This mixed method study used a pre-test/post-test design to evaluate the efficacy of a teaching strategy in improving beginning nursing student learning outcomes. During a 4-week student teaching period, a convenience sample of 54 sophomore level nursing students were required to complete calculation assignments, taught one calculation method, and mandated to attend medication calculation classes. These students completed pre- and post-math tests and a major medication mathematic exam. Scores from the intervention student group were compared to those achieved by the previous sophomore class. Results demonstrated a statistically significant improvement from pre- to post-test and the students who received the intervention had statistically significantly higher scores on the major medication calculation exam than did the students in the control group. The evaluation completed by the intervention group showed that the students were satisfied with the method and outcome.

Nursing students' mathematic calculation skills

This mixed method study used a pre-test/post-test design to evaluate the efficacy of a teaching strategy in improving beginning nursing student learning outcomes. During a 4-week student teaching period, a convenience sample of 54 sophomore level nursing students were required to complete calculation assignments, taught one calculation method, and mandated to attend medication calculation classes. These students completed pre- and post-math tests and a major medication mathematic exam. Scores from the intervention student group were compared to those achieved by the previous sophomore class. Results demonstrated a statistically significant improvement from pre- to post-test and the students who received the intervention had statistically significantly higher scores on the major medication calculation exam than did the students in the control group. The evaluation completed by the intervention group showed that the students were satisfied with the method and outcome.

Drug calculations: are they safer with or without a calculator?

The safe administration of medicines is a key nursing activity. The most common type of medication error is administering the wrong dose (Armitage, 2006). To administer medicines correctly, nurses must apply appropriate knowledge specific to the patients receiving medication, and execute the skills required to administer medicines to a high degree of accuracy. This may include mathematical calculations. The potential for errors in child health settings is compounded by the complex calculations often required to ensure children receive the appropriate dose. Nurse educators face dilemmas in both pre- and post-registration settings relating to students' lack of ability to undertake drug calculations without a calculator. This means that students may not be able to follow the Nursing and Midwifery Council (NMC) Guidelines for the Administration of Medicines (NMC, 2004b). Medication dosage calculations continue to be problematic for qualified nurses. It is too early to assess whether changes in state education will improve pre-registration students' abilities to apply skills in basic mathematical principles to drug calculations. In the meantime, it is important that nurses who appear to have a weakness in applying mathematical principles to drug calculations seek, and are offered, the opportunity to develop these skills.

Improving Medication Calculation Skills of Practicing Nurses and Senior Nursing Students

Medication administration is an essential nursing competency as calculation difficulties can lead to serious medication errors. Nurses involved in staff education need to be aware of methods to assess for computation difficulty and develop strategies for nurses to improve their computation abilities. The purposes of this quasi-experimental pilot study were to assess the medication calculation skills of nurses and nursing students and to determine the effectiveness of teaching strategies aimed at improving these skills.

Concerns about numeracy skills of nursing students

Accurate mathematical calculation is a critical skill that nurses must demonstrate in order to administer medications safely. The ability of undergraduate nurses to calculate the correct dosage of medication consistently has been a concern of schools of nursing for a long time. This study explores the ability of a group of nursing students to calculate mathematical drug problems within an English University. A convenience sample of 37 second year nursing students volunteered to complete a 10-item drug calculation test, requiring understanding of simple division and multiplication, percentages, ratio and proportion, conversion of units and multiple-stage procedures. The students' median correct score was 6 out of 10 (range 0-9). No one achieved full marks. Only 3 were able to achieve 9 out of 10, indicating that, on average, students were unable to achieve 90% mastery. This finding supports past literature and is of concern. It is of concern that these student nurses did not have the ability to perform drug calculations at a 90% mastery level. It has been recommended that admission requirements be reviewed, and that students are tested throughout their programme and that skills are reinforced both in the classroom and practice setting. This could be achieved using a variety of methods, supporting a teaching and learning framework to integrate analytical and procedural competence underpinned by the creation of national standards. Also, both educators and practitioners must take responsibility for ensuring adequate support and guidance are available to student nurses.

Finnish nurses' and nursing students' mathematical skills

The health care environment requires that practitioners have sufficient mathematical skills to perform accurate, safe and effective medication administration. This is a highly responsible and nursing task, which is performed daily. In this study 364 nurses and 282 graduating nursing students in Finland completed the Medication Calculation Skills Test (MCS Test). According to the findings students lacked accurate mathematical skills, while nurses attained higher scores in the test. Nurses with an upper secondary school education managed better with the calculation problems than nurses with a lower basic education. Students who had an excellent mark (9-10) in mathematics, had studied mathematics longer at high school and were more satisfied with the amount of medication calculation instructions and scored higher in the MCS Test than others. The differences between the nurses' and students' mathematical skills were significant. The MCS Test could be used to measure one's own skills and to give information of the mathematical skill level for constructing a nursing curriculum or additional training for clinical practice.

Finnish nurses' and nursing students' pharmacological skills

PURPOSES AND OBJECTIVES: The purposes of this study were to investigate the pharmacological skills of Finnish nurses and graduating nursing students, to determine how pharmacological skills are related to background factors and to identify differences between nurses and students and, finally, to examine how the instrument used, the Medication Calculation Skills Test, works.

BACKGROUND

Pharmacology is a relevant and topical subject. In several studies, however, pharmacological skills of nurses and nursing students have been found insufficient. In addition, pharmacology as a subject is found to be difficult for both nursing students and nurses.

DESIGN AND METHODS

The study was evaluative in nature; the data were collected using the Medication Calculation Skills Test, developed for the purposes of this study. The instrument was used to gather information on background factors and self-rated pharmacological and mathematical skills and to test actual skills in these areas.

RESULTS

Results concerning pharmacological skills are reported in this paper. The maximum Medication Calculation Skills Test score was 24 points. The mean score for nurses was 18.6 and that for students 16.3. Half of (50%) the students attained a score of 67% and 57% of nurses attained a score of 79%.

CONCLUSIONS

Nurses and students had some deficiencies in their pharmacological skills. Nurses had better pharmacological skills than students according to both self-ratings and actual performance on the test.

RELEVANCE TO CLINICAL PRACTICE

It is vitally important that nurses have adequate pharmacological skills to administer medicines correctly. This study showed that the Medication Calculation Skills Test seems to work well in measuring pharmacological skills, even though it needs further evaluation. Findings from this study can be used when planning the nursing curriculum and further education for Registered Nurses.

Using Dimensional Analysis to Improve Drug Dosage Calculation Ability

Confidence and accuracy in medication calculation ability continue to be problematic among nursing students. This deficiency has been attributed to poor basic mathematical skills, inconsistent teaching methods, and inconsistent or incorrect use of multiple mathematical formulas. This article provides evidence of the value of dimensional analysis as an effective teaching strategy for calculating drug dosages.

Medication calculation skills of nurses in Finland

The aim of this study was to describe the medication calculation skills of nurses in Finland. We tried to ascertain how nurses evaluate their own medication calculation skills and how these self-evaluations are associated with various background factors and the actual level they score in a calculation test. In the spring of 2000, nurses (n = 546) in one Finnish university hospital completed a questionnaire specially developed for this study. The instrument included structured questions, statements and a medication calculation test. The response rate was 56%. Data analysis was based on descriptive statistics. The nurses found the mathematics and dosage calculation easy and interesting but the pharmacology difficult. They evaluated their own mathematical and dosage calculation skills as sufficient, although it had certain shortcomings. The youngest nurses (20-29 years) evaluated their mathematical and dosage calculation skills as sufficient and they also succeeded in the calculation test. Basic (High School) education was associated with better calculation skills. The findings of this study support the need and importance of checking and maintaining one's medication calculation skills.

Adverse events in drug administration: a literature review

Discussions between the children's services manager at an National Health Service trust, and a children's nursing lecturer from the trust's partnering university clarified that there was a need to establish a greater understanding of the local circumstances surrounding adverse events in drug administration - particularly when those events involved nurses. Indeed it is claimed that nurses spend up to 40% of their time administering drugs. It was agreed that a collaborative research study, specifically designed to explore the nature of drug administration errors, could inform future trust policies and procedures around both drug administration and error, as well as the various university curricula concerning drug administration. This study, supported by senior management in the trust, and the chair of the local research ethics committee, has commenced. The first part of this study -- an introductory literature review, is presented here. The work of O'Shea [J Clin Nurs (1999)8:496-504] is significant in structuring the review that bears a number of recurring themes. It is not the intention of this literature review to reappraise O'Shea's original critique but to expand on her work, offer a contemporaneous perspective in the light of studies and reports published since 1999, and reset the topic in the context of clinical governance. This literature review has already provided an underpinning framework for a pilot questionnaire to staff who have been involved in drug administration errors and is also the basis for curricular input to preregistration students on the subject of risk management and drug administration. In conclusion, several recommendations about the shape of future research are offered.

Error and time delay in pediatric trauma resuscitation: addressing the problem with color-coded resuscitation aids

This article concentrates on two pediatric specific factors operational in pediatrics therapeutics 1) the necessity to perform calculations; and 2) the lack of recognition of significant pediatric error. Resuscitation aids and their optimal function in pediatric trauma resuscitation are examined.

The 4 Cs: a model for teaching dosage calculation

Performing dosage calculation can be viewed as the ability to perform the 4 Cs: compute, convert, conceptualize, and critically evaluate. Ability to perform the 4 Cs is dependent on a variety of student and program factors. A model for teaching dosage calculation, grounded in research on mathematical success, is presented. Strategies for teaching dosage calculation based on this model are discussed.

Medication calculation skills of practicing paramedics

OBJECTIVE

To assess the medication calculation skills among a group of practicing paramedics, the types of computations they find most difficult, and the relationship between drug calculation skills and various demographic characteristics.

METHODS

A demographic survey and a ten-item drug calculation examination were administered to a convenience sample of 109 practicing paramedics representing a cross-section of emergency medical services (EMS) system characteristics in North Carolina. Examinations were scored independently by two graders and error types were assigned to incorrect responses. Examination results were then correlated with demographic and EMS system characteristics.

RESULTS

Overall performance on the drug calculation examination was poor. The mean score was 51.4% (SD 27.4). Intravenous flow rate problems and medication bolus problems were calculated correctly in 68.8% of the cases, followed by non-weight-based medication infusions (33.9%), weight-based medication infusions (32.5%), and percentage-based medication infusions (4.5%). Examination scores were higher among paramedics with college level education, but scores were lower among paramedics with more years of EMS experience. Conceptual errors (i.e., errors in setting up the problem) were more prevalent than mathematical errors, errors in weight conversion, or errors in unit conversion (e.g., grams to milligrams). The participants reported that drug calculations were infrequently performed in daily practice and were rarely a topic of continuing education programs.

CONCLUSION

Similar to findings among other allied health professions, medication calculation skills were found to be lacking among a group of practicing paramedics. In addition, the paramedics reported infrequent opportunities to perform this skill in the clinical setting and that medication calculations were not a routine part of EMS continuing education programs.

Factors contributing to medication errors: a literature review

Drug administration is an integral part of the nurse's role. Responsibility for correct administration of medication rests with the nurse, yet medication errors are a persistent problem associated with nursing practice. This review examines what constitutes a medication error and documents contributory factors in medication errors. These factors have been derived from reported medication errors and opinions of nurses as to factors which predispose to errors. A number of definitions exist as to what constitutes a medication error. The definition used should facilitate interpretation and comparison of a wide range of research reports. Medication errors are a multidisciplinary problem and a multidisciplinary approach is required in order to reduce the incidence of errors.

Dosage calculation testing for competency in ambulatory care

The scope of services provided by the Staff Development Department or clinical educators in healthcare settings includes, but is not limited to, employee orientation, continuing education, and competency assessment. The critical issue of ascertaining competency of nursing staff in medication dosage calculation encompasses each of these functions. The authors describe the process of pilot testing a dosage calculation test in an ambulatory care setting, adapting it based on feedback, using it with orientees and current staff, and using the educational process with nurses needing assistance in dosage calculation.

Enhancing math competency of baccalaureate students

The result of a 4-year effort to study and institute changes in Baylor University School of Nursing's baccalaureate (BSN) students' math competencies was successful. The evolution of the current math competency process is detailed. By identifying at-risk, entry-level students through math examination in the junior I semester and each semester in the program, individual clinical faculty can customize the teaching-learning experience for students. Students who need more help than a clinical instructor has available, which is documented by semester examination failure, benefit from taking a 1-hour medication administration course before graduating from the BSN program. Insights and suggestions are offered for other schools encountering this problem.

Refinements in the dimensional analysis method of dose calculation problem-solving

Although the dimensional analysis method for solving dose calculation problems is gaining acceptance with nurse educators, many inconsistencies in teaching methodologies remain that can be confusing to both students and practicing nurses. The author presents refinements to the dimensional analysis method which can improve speed and accuracy in dose calculations and will be universally applicable to all types of clinical dosage problems.

Numeracy needs of the beginning registered nurse

The literature indicates: Nursing students demonstrate serious numeracy skills deficits. Consensus that such skills are necessary, particularly for medication administration. Diagnostic testing and remediation are desirable, or basic mathematics is pre-requisite for entry into nursing courses. Calculation skills mastered at one point in time diminish if ongoing practise is not maintained. The frequency with which nurses perform drug calculation in the clinical setting is decreasing. This study aimed to identify and analyze numeracy skills required by beginning registered nurses to facilitate development of numeracy skills by nursing students. A convenience sample of metropolitan and rural health care facilities in New South Wales (NSW) was selected. Within each facility an area where nursing graduates customarily work was selected. Numeracy input required to complete patients' charts was identified. Additional counting, measuring or computation the nurses performed was also identified. Except for paediatric areas, the frequency with which a nurse has to perform other than a simple calculation in order to administer a medication, or calculate a per minute drip rate is low. However, the necessity to calculate drug doses does exist. Creative ideas are needed to enable nurses to do this accurately. Three general approaches are suggested. A number of recommendations are presented.

Mathematical Calculation Ability and Mathematical Anxiety of Baccalaureate Nursing Students

Accurate mathematical calculations are a critical skill that nurses must demonstrate in order to safely administer medications. This study was designed to investigate differences in mathematical calculation ability and mathematical anxiety for a group of baccalaureate nursing students (n = 56) and a group of undergraduate students majoring in fields other than nursing (n = 56). Results showed the nursing students had significantly lower mathematical skills test performance than the non-nursing students. No group differences were found for mathematical anxiety. These results are consistent with previous findings that indicate that nursing students are seriously deficient in mathematical skills. The greater deficiency in mathematical skills performance noted in the nursing group indicates that nursing education must consider more selective admission requirements related to mathematics. Mathematical calculation skills must be evaluated early in the program of study and educational opportunities to increase mathematical proficiency must be planned throughout the nursing program.

Medication calculation ability of registered nurses

A convenience sample of 110 registered nurses in four western states completed a demographic questionnaire and a 20-item medication calculation test to investigate errors in medication calculation that contribute to medication error rates. Intravenous questions were most difficult, then oral, then intramuscular/subcutaneous items. Nurses erred more when more than one calculation was required and when milligram to grain conversion was needed. Nurses who rated their skill and comfort with medication calculation above average scored higher. Yet 81 percent of the nurses were unable to correctly calculate medications 90 percent of the time and 43.6 percent of the test scores were below 70 percent accuracy. Strategies are suggested which may be used in staff development in identify registered nurse medication calculation abilities and to enhance these skills in practicing nurses.