The Role of Simulation Training in Reducing Medication Administration Errors Among Nursing Staff

Introduction

Medication administration errors remain among the most frequently documented categories of preventable patient harm in acute care hospitals, with estimates suggesting that a clinically significant proportion of hospitalized patients experience at least one medication-related error during their admission (Institute for Safe Medication Practices, 2022). While systems-level factors such as staffing, workflow design, and technology adoption have received considerable research attention as determinants of medication safety, the individual competency of the nurse performing the administration task remains a foundational and modifiable contributor to error prevention. Traditional medication safety education in nursing has relied predominantly on didactic instruction, including lectures, written modules, and case-based discussion, formats that convey knowledge effectively but offer limited opportunity for nurses to practice the psychomotor, procedural, and decision-making skills required during actual high-risk medication events.

High-fidelity simulation training has emerged over the past two decades as a widely adopted strategy in nursing education, allowing learners to practice clinical skills in a realistic, risk-free environment that closely approximates the cognitive and physical demands of actual patient care. Simulation-based learning is grounded in experiential learning theory, which posits that skill acquisition and retention are strengthened through active practice, immediate feedback, and structured reflection, processes that are difficult to replicate in a purely didactic format (Kolb, 2015; Jeffries, 2020). For medication administration specifically, simulation offers the opportunity to rehearse high-risk scenarios, such as interruption during preparation, look-alike/sound-alike drug confusion, or high-alert medication dosing, under conditions that mirror the pressures of actual clinical practice without exposing patients to risk.

A growing body of literature has examined simulation-based education across a range of nursing competencies, generally reporting favorable effects on knowledge acquisition, clinical judgment, and confidence (Cant & Cooper, 2017; Hayden et al., 2019). Fewer studies, however, have isolated medication administration error rate as a direct, objectively measured clinical outcome following simulation training, with much of the existing evidence instead relying on knowledge test scores or self-reported confidence as proxy measures. Additionally, existing comparative studies examining simulation against standard didactic training for medication safety specifically have often been limited by small sample sizes, single-site designs, or short follow-up periods insufficient to assess retention of training effects over time.

Given the persistent burden of medication administration error and the theoretical advantages of experiential learning for high-risk procedural tasks, further evidence directly comparing simulation-based and didactic training approaches, using objectively measured clinical error outcomes over a clinically meaningful follow-up period, is warranted. The purpose of this study was to evaluate the effect of a structured, high-fidelity simulation-based medication safety training program on medication administration error rates among registered nurses, compared to nurses receiving standard didactic instruction covering equivalent content, and to assess whether any observed effect persisted over a 12-week post-training period.

Methods

This study employed a quasi-experimental, two-group comparative design conducted across four adult medical-surgical units located within two acute care hospitals in the same regional health system. Units were assigned to either the simulation-training arm or the didactic-training arm based on hospital site to minimize contamination between training conditions among nurses working on the same unit. Registered nurses providing direct patient care and responsible for medication administration on the participating units were eligible for inclusion. Nurses with less than three months of employment on the unit at the time of enrollment, and those unable to attend the full training session, were excluded. A total of 168 nurses were enrolled: 84 in the simulation-training arm and 84 in the didactic-training arm.

Both training arms received training of equivalent duration, approximately four hours, covering identical core content areas: high-alert medication management, the five rights of medication administration, interruption and distraction mitigation strategies, and recognition of look-alike/sound-alike medication risk. The simulation-training arm completed this content through four scenario-based sessions using high-fidelity mannequin simulators programmed to reflect physiologic responses to correct and incorrect medication administration, with each scenario followed by a structured debriefing session led by a certified simulation facilitator. The didactic-training arm received the equivalent content through a facilitator-led lecture format supplemented by written case studies, without hands-on scenario practice.

Three primary data elements were collected for analysis:

1.Medication administration error data for each participating nurse, tracked for 12 weeks following training completion using a combined direct-observation audit and the hospital’s electronic voluntary incident reporting system, with errors classified by type and severity using the NCC MERP index.

2.Medication safety competency scores, obtained using a validated 25-item written and scenario-based competency assessment administered immediately prior to training, immediately following training, and again at the 12-week follow-up point.

3.Self-efficacy ratings, collected using a validated self-efficacy scale addressing nurses’ confidence in managing high-risk medication administration scenarios, administered at the same three time points as the competency assessment.

The primary outcome was the medication administration error rate during the 12-week post-training period, expressed as errors per 1,000 doses administered. Multivariate Poisson regression with robust standard errors was used to compare error rates between groups, adjusting for nurse years of experience, unit acuity, and shift type, with the natural logarithm of total doses administered included as an offset term. Secondary outcomes, including competency score and self-efficacy rating, were compared between groups using independent-samples t-tests. Statistical significance was set at p < .05, and analyses were conducted using Stata version 18.

Results

Baseline characteristics, including years of nursing experience, prior simulation exposure, and pre-training competency scores, did not differ significantly between the simulation-training and didactic-training groups (all p > .05), supporting comparability between arms. Over the 12-week post-training follow-up period, a combined total of 39,540 medication doses were captured across both study arms through the direct-observation and incident-reporting data sources.

The post-training medication administration error rate was significantly lower in the simulation-training group, at 3.6 per 1,000 doses administered, compared to 7.4 per 1,000 doses in the didactic-training group. In the adjusted Poisson regression model, nurses who received simulation-based training demonstrated approximately half the incidence of medication administration errors relative to those who received standard didactic training (incidence rate ratio = 0.49, 95% CI 0.36–0.66, p < .001), after adjusting for years of experience, unit acuity, and shift type.

Medication safety competency scores at the 12-week follow-up were significantly higher in the simulation-training group (M = 87.2, SD = 7.6) compared to the didactic-training group (M = 75.9, SD = 9.4; t(166) = 8.71, p < .001). Notably, while both groups showed comparable gains immediately following training, the didactic-training group demonstrated substantially greater decay in competency scores between the immediate post-training assessment and the 12-week follow-up, whereas the simulation-training group retained the majority of its immediate post-training gains. Self-efficacy ratings followed a similar pattern, with simulation-trained nurses reporting significantly greater confidence in managing high-alert medication scenarios (M = 4.4 of 5) compared to didactically trained nurses (M = 3.6 of 5; p < .001). Analysis of error type revealed that the simulation-training group showed the largest relative reduction in errors associated with interruption-prone tasks and high-alert medication dosing, categories directly targeted by the scenario-based training content, while reductions in wrong-time and documentation-related errors were more modest and did not differ significantly between groups.

Discussion

The findings of this study indicate that high-fidelity simulation-based training produced a substantial and statistically significant reduction in medication administration errors relative to standard didactic instruction covering identical content, with nurses in the simulation arm demonstrating approximately half the error incidence of their didactically trained peers over a 12-week follow-up period. These findings extend prior simulation research, which has predominantly relied on knowledge and confidence measures, by demonstrating a measurable effect on an objectively tracked, clinically meaningful patient safety outcome (Cant & Cooper, 2017; Hayden et al., 2019).

The pattern of competency score retention observed in this study offers a plausible explanation for the sustained reduction in error rate among simulation-trained nurses. While both training modalities produced comparable immediate gains in knowledge and skill, the didactic-training group exhibited more pronounced decay over the 12-week follow-up period, consistent with established learning theory suggesting that passively acquired knowledge is more susceptible to forgetting than skills reinforced through active practice and structured feedback (Kolb, 2015). The debriefing component embedded within each simulation scenario likely played a particularly important role in this effect, as structured reflection following simulated performance has been shown to strengthen the encoding of procedural and decision-making skills relative to lecture-based instruction alone (Jeffries, 2020).

The disproportionate reduction in interruption-related and high-alert medication errors within the simulation-training group is also notable, as these error categories map directly onto the specific scenarios rehearsed during training. This finding suggests that simulation may confer its greatest benefit not as a general educational enhancement, but as a targeted intervention capable of building resilience against the specific situational risk factors most strongly associated with error, such as distraction during preparation and complexity of high-alert dosing calculations. This targeted specificity may have implications for how simulation curricula are designed, suggesting that programs deliberately structured around an institution’s most common or highest-severity error patterns may yield greater safety returns than generic skills-based simulation content.

This study has several limitations. The quasi-experimental design, with training arm assigned at the site level rather than through individual-level randomization, introduces the possibility of residual site-level confounding related to unit culture or leadership that could not be fully addressed through statistical adjustment. The relatively short 12-week follow-up period, while sufficient to demonstrate a divergence in competency retention between groups, does not establish whether the observed benefit of simulation training persists over longer time horizons, and periodic refresher training may be necessary to sustain the effect. The resource intensity associated with high-fidelity simulation, including equipment costs and dedicated facilitator time, may also present an implementation barrier for hospitals with limited simulation infrastructure, and future research examining the cost-effectiveness of simulation-based medication safety training relative to its associated reduction in adverse drug events would be valuable in informing broader adoption. Despite these limitations, the magnitude and consistency of the findings support the integration of high-fidelity, scenario-based simulation into ongoing medication safety education for nursing staff, and suggest that simulation may offer a meaningfully more durable safety benefit than traditional didactic training approaches alone.

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