Using Clinical Simulation to Improve the Medication Administration Process
Medication administration errors contribute to thousands of patient deaths each year. (1) Errors occur frequently related to missed actions in the medication use process with nearly 50% of all errors in doses and prescriptions attributed to missing a step. (2) Recently the nursing community followed with dread the case of RaDonda Vaught (3) whose workaround within her hospital’s incommodious med admin system led to a patient’s death and her criminal conviction. The habit of overriding automated dispensing cabinets (ADC) has become so common, so concerning, and perceived as such a serious threat to patient safety that the Joint Commission has advocated for the use of an override assessment process (4) for hospitals.
There are many reasons why a nurse might choose to override an ADC system, but much of it likely boils down to the impacts of trying to work in flawed systems, Systems thinkers and human factors (5) professionals are very well versed in how this intersection of institutional, human, and machine elements can collide in the most tragic ways.
Healthcare simulation can certainly assist in improving systems, but clinical simulation is not always leveraged for this purpose in a meaningful way. This article suggests ways that healthcare simulation can be used to improve knowledge of how healthcare simulation and technology (6) can help to prevent medication administration errors. (7)
The complexity within systems can be caused by the frequency of medication administration and the potential for grave consequences when failure happens. Yet, there is a clear imperative to act to improve all aspects of medication delivery and improve understanding of where systems help or hurt these efforts. Simulation-based interprofessional education can and should be the answer.
This 6+ hour course is designed to help clinical educators learn how to best identify, design, integrate, and assess the use of clinical simulation when training for medication administration. Alarming error statistics and the need for improved medication administration practices are demonstrated, with the knowledge, tools, and resources provided to begin addressing those concerns. Additionally, the course includes a breakdown of innovative clinical simulation technologies effective in providing med admin training and two simulation scenario templates!
Healthcare simulation enhanced medication administration education has been shown to improve medication administration safety (8) and the feasibility of implementing (9) such types of simulation demonstrated is well established. (10) Despite study outcomes that show the promise of simulation as a tool to improve medication administration safety, the available literature still lacks comprehensive examples of such efforts inclusive of multi-professional teams and the use of simulated equipment common as part of the process.
Clinical Simulation programs are well suited to support medication error research further! Large simulation centers with full complements of simulated spaces (e.g. nursing stations, pharmacies, patient units) and machinery such as Automated Dispensing Computers, are prime venues for such simulation-based, interprofessional medication administration process education to occur.
With some safety measures and planning in place, actual hospitals could also employ simulation to teach interprofessional teams how to mitigate medication administration process errors as well as utilize designed scenarios to assist in uncovering where their systems are weak.
Moreover, healthcare systems with educational arms that are integrated could use reported near-miss events, errors, and never events to formulate the basis of their scenarios so that their participants are literally able to learn from their own mistakes (which, as we all know, are powerful learning catalysts), by their actual teammates, on their own equipment. In this way the entire system gains the opportunity to learn ways to improve their medication administration process and lessen their burden from safety issues within their environment, saving lives and dollars.
Systems need to invest time and human and monetary resources to create complex branched scenarios around the medication administration process that are designed to include the full complements of healthcare team members typically involved in getting medication from prescribed to administered. While scenarios exist to teach aspects of this process they often focus on a single point in the process and a single provider type.
These are noble pursuits, but their narrow scope and missing system components do not sufficiently supply opportunities for the process to improve or for key personnel to appreciate how the system pieces interact to produce good or bad outcomes. It’s like trying to see the whole picture in a puzzle but only assembling the edge pieces.
Appropriate scenarios would not only include the disciplines of medicine, nursing, and pharmacy, but also include simulated or actual CPOE systems, ADCs, pharmacy equipment typically used, an actual or simulated clinical space, and a standardized patient. Additionally, a variety of medications should be depicted across sets of scenarios including those that are frequently prescribed, in the high-alert medication (11) category, those that require calculations to administer, those with a high risk of untoward responses, and those that require careful monitoring prior to and following administration. Ideally, scenarios should include depictions of patients at a variety of ages due to the fact that age can impact dosing and responses to medications.
Once implemented, programs should aim to evaluate the intervention and publish their experiences and outcomes so the community of practice can benefit from the efforts undertaken. Examples of published works found in the literature may represent a starting place for building a simulation-based IPE medication administration (12) process program. While this suggested use of simulation requires much effort on the part of educators and key stakeholders the potential for it to benefit providers, institutions, and patients is worth the effort.
Jill Sanko is an award-winning PhD-prepared nurse scientist. She began her research career as a research nurse at the National Institutes of Health (NIH). During her almost decade of service at NIH, she worked in several capacities including as support research staff and as an associate principal investigator. She was also integral in establishing the NIH Clinical Center’s simulation and patient safety program. In 2008 she moved back to Miami where she joined the University of Miami first at the Center for Patient Safety and later at the School of Nursing and Health Studies where she continued teaching and researching the impacts of simulation-based education on patient safety.
With over 40 publications in these areas and numerous national and international presentations she has helped to build the body of knowledge in using simulation as a technology to improve patient safety and has been recognized for these efforts including authoring two Articles of Influence, induction into the Academy for the Society for Simulation in Healthcare, recognition as an INACSL -Frontline Simulation Champion, and a Breakthrough Learning Hero of Healthcare Simulation. Currently, she is a contributing faculty member at Walden University and an Adjunct Associate Professor at MGH-IHP.