The effect of peer-assisted learning on medication error occurrence among undergraduate nursing students: A randomized controlled trial

Abstract

BACKGROUND:

Medication administration is one of the most sensitive duties of nurses and an essential part of the treatment and care process. Nursing students are more likely to make medication errors because of their inexperience and lack of ability. The importance of clinical education using modern approaches is undeniable. This study was conducted to investigate the effect of peer-assisted learning on medication error occurrence among undergraduate nursing students.

MATERIALS AND METHODS:

This study is a randomized controlled trial, conducted in 2023–24, involving 50 fourth-semester undergraduate nursing students at a nursing school in Tehran, Iran. Students were chosen through a census method, and randomly divided into intervention and control groups. The intervention group was taught pharmacotherapy via peer teaching, and data were collected using the Medication Error Occurrence Questionnaire (MEOQ). The data analysis was performed using SPSS software, and descriptive statistical tests such as mean, SD, frequency, and percentage were employed. Several other statistical tests were utilized, including Fisher’s exact test, Chi-squared test, independent t-test, and paired t-test.

RESULTS:

Before the intervention, there were no significant differences in medication error occurrence between the intervention and control groups (P > 0.05). Upon utilizing peer teaching, the intervention group exhibited significant reductions in medication error occurrence, from 65.76 ± 9.75 to 56.76 ± 13.69 (P = 0.001). In contrast, the control group experienced a slight reduce in medication error occurrence level, from 68.32 ± 12.41 to 66.28 ± 18.94 (P = 0.276).

CONCLUSION:

Peer teaching significantly reduced nursing students’ medication error occurrence, recommending its adoption as an innovative educational method. It is recommended that the peer method be used to improve the clinical education of nursing students.

Introduction

Medication errors are the most frequent kind of medical errors, and because of their great frequency and possible patient dangers, hospitals frequently utilize them as a gauge of patient safety.[1] Medication administration is one of the most sensitive duties of nurses and an essential part of the treatment and care process.[2] Errors in this area might have very negative effects on patients.[3]

According to research conducted by Farajzadeh et al.,[4] 104 nurses who participated in the survey experienced at least one medication mistake over the preceding six months. From their point of view, the highest mistake ratings were associated with drugs, patients, ward conditions, nurses’ mental health, and doctors. Errors happen when a medical professional picks the wrong approach to treatment or chooses the right approach but administers it incorrectly.[5]

Administering medication accurately to patients is one of the fundamental competencies of nurses. However, with the increasing number and variety of medications, this task has become more challenging and complex.[4] Rapid advancements in medical technology, existing deficiencies in nursing education, and high public expectations of nurses contribute to significant stress levels among nurses, thereby creating conditions that facilitate the occurrence of errors.[6]

Medication errors occur when the five principles of proper medication administration—right patient, dose, drug, time, and method—are not adequately observed, or when the prescribed medication is not administered to the patient.[2] Such errors can lead to a range of consequences, including increased mortality rates, prolonged hospital stays, and higher healthcare costs. Additionally, these mistakes can erode patient trust, resulting in dissatisfaction with healthcare systems, and cause stress and ethical conflicts for nurses.[7]

Compared to experienced personnel, nursing students are more likely to make medication mistakes because of their inexperience and lack of ability.[8] For example, 26% of nursing students have made prescription mistakes, according to research by Simonsen et al.[9] Likewise, Khalili et al.’s[10] study revealed a high percentage of medication mistakes among nursing students, highlighting the necessity of tactics to lower these errors in nursing education programs. These results are supported by Yaghoubi et al.’s[8] study of a low incidence of error reporting and a high prevalence of medication errors among nursing students.

These findings underline the importance of integrating comprehensive training and error prevention strategies into nursing curricula to enhance patient safety and build students’ clinical competence.

The significance of education as one of the most vital components of nursing care is undeniable.[11] Clinical education, however, exhibits more deficiencies compared to other areas of nursing education.[12] Consequently, employing innovative approaches to support the training of nurses is imperative.[13] Various methods exist for disseminating information and education, with simplicity, accessibility, and cost-effectiveness being critical criteria for selecting these methods.[11]

It seems that to foster more sustainable learning and enhance the quality of clinical education, a shift in teaching methods is necessary, with an emphasis on greater engagement of learners in the educational process.[14] One widely utilized approach in medical education is peer teaching,[15] which is defined as the development of knowledge and skills through active assistance and support from individuals at a similar level.[16] The goal of this teaching method is to enhance knowledge, attitudes, and behavioral change, facilitated by individuals who may not be formally trained in the subject but share common experiences.[17]

Evidence from various educational settings indicates that peer teaching benefits both the peer teacher and the learner, making it a valuable method for engaging participants.[18]

Given the critical importance of addressing medication errors and the necessity of adopting innovative teaching strategies to improve nursing students’ clinical care education, the researchers aimed to investigate the impact of peer teaching on the incidence of medication errors among nursing students.

Materials and Methods

Study design and setting

This study was an experimental research designed as a randomized controlled trial, conducted during 2023–24 at a school of nursing in Iran.

Study participants and sampling

The study participants consisted of 50 fourth-semester undergraduate nursing students, who were included in the research through a census sampling method. They were then randomly divided into two groups—peer-education group (25 students) and control group (25 students)—by a research assistant blinded to the study design using a coin flip.

The inclusion criteria were: being enrolled in the fourth semester of undergraduate nursing, not having participated in any pharmacotherapy training courses outside university classes in the past six months, and willingness to participate in the study. Exclusion criteria included unwillingness to continue participation and incomplete responses to the questionnaires.

All participating students provided informed consent and remained in the study until its completion, with no dropouts reported.

Data collection tool and technique

To conduct the study, the researcher coordinated with the clinical program coordinator to select the largest affiliated teaching hospital, which had the capacity to host and provide clinical training for all research participants. After obtaining permission from the university, the researchers introduced themselves to the participants and explained the purpose of the study to gain their consent to participate. Ethical considerations were observed in accordance with the Declaration of Helsinki.[19] Participants were assured about the confidentiality of their information, the optionality of providing names on the questionnaires, and their right to withdraw from the study at any stage. Informed consent was obtained from all participants.

Both before to and one month following the intervention, the individuals filled out the questionnaires. The experimental group received peer-based instruction on pharmacotherapy concepts as part of the intervention. Peer educators were given the lesson plan and instructional materials at the start of the intervention, which had been approved by three clinical instructors. Furthermore, the researcher, a faculty member with 15 years of clinical nursing education expertise, trained the peer educators.

The peer educators delivered the educational content to the students in the experimental group using a lecture-based method across three 60-minute sessions, followed by a 30-minute Q and A session at the end of each class. To reinforce the theoretical training, bedside teaching was conducted by the peer educators in clinical wards where students were undergoing internships. Educational tools, including a computer and a projector for presenting PowerPoint slides, were utilized to enhance the delivery of the content.

Meanwhile, the control group continued to receive the standard training provided by clinical instructors from the faculty, without any additional intervention. One month after the intervention, both groups completed the research instruments again. The research process is illustrated in Figure 1.

Figure 1.

The study process

The data collection instruments included questionnaires addressing demographic characteristics and the occurrence of medication errors. These questionnaires were administered in two stages: a pre-test and a post-test. Students completed the questionnaires at both stages, providing data for subsequent analysis.

The Personal Information Form gathered details such as age, gender, place of residence, interest in the nursing field, overall grade point average (GPA), and the clinical internship ward. The Medication Error Occurrence Questionnaire (MEOQ) is a researcher made questionnaire containing 27 items that was developed based on referencing prior research.[20,21] Its components include: Medication Errors (10 items), Fear of Reporting Consequences (9 items), Managerial Barriers to Reporting (5 items), and Process Barriers to Reporting (3 items). The scoring system for the questions was based on a five-point Likert scale, ranging from (Very Low (1), Low (2), Moderate (3), High (4), and Very High (5). An average score was calculated for each domain, where a lower mean indicated fewer errors, and a higher mean reflected more frequent errors.

The overall score was categorized as follows:

• 0–44: Low occurrence,

• 45–89: Moderate occurrence,

• 90–135: Severe occurrence.

The questionnaire’s validity was reassessed and approved by a panel of 10 faculty members specializing in nursing and medical education (PhDs in Nursing and Medical Education). Its reliability was confirmed with a Cronbach’s alpha coefficient of 0.84.

During the study, students in the control group received only the standard clinical training by instructors. To prevent contamination bias, data were first collected from the control group, followed by the intervention group. Finally, the data analysis was performed using SPSS software, and descriptive statistical tests such as mean, SD, frequency, and percentage were employed. Several other statistical tests were utilized, including Fisher’s exact test, Chi-squared test, independent t-test, and paired t-test.

Ethical consideration

The study was approved by Ethics Committee of Aja University of Medical Sciences (IR.AJAUMS.REC.1402.104). Informed consent was obtained from all participants. The study was carried out according to the ethical principles of the World Medical Association’s Declaration of Helsinki. The optionality of entering the study, the right to withdraw from the study at any time, and respecting the confidentiality of the data were other considerations observed in this study. Also, the Committee on Publication Ethics principles were considered in publishing.

Results

The results of the Kolmogorov-Smirnov test confirmed the normal distribution of the data (P > 0.05). Consequently, parametric statistical tests were employed for data analysis, including descriptive statistics (mean, standard deviation, absolute and relative frequency) and inferential statistics (Fisher›s exact test, Chi-square test, independent t-test, paired t-test). A significance level of P < 0.05 was considered. The statistician conducting the analysis was blinded to the allocation of participants into the intervention and control groups.

The mean age of the participating students was 21.08 ± 0.665 years, ranging from 19 to 22. Most participants were female (56%) and single (88%). The majority resided in dormitories (82%) and lacked clinical work experience (94%). Additionally, most participants reported a moderate level of interest in nursing (36%). The demographic characteristics of participants in the intervention and control groups were statistically homogeneous (P > 0.05, Table 1).

Table 1.

Individual characteristics of research units

Group				Intervention				Control				P
Variable				Mean (SD)				Mean (SD)
Age (y)				21.120 (0.781)				21.040 (0.538)				P=0.675
GPA (Grade Point Average)				17.282 (1.148)				17.036 (0.828)				P=0.391
Variable				f		%		f		%		P
Sex		Female		11		44		17		68		P=0.154
		Male		14		56		8		32
Marital status		Single		23		92		21		84		P=0.667
		Married		2		8		4		16
Place of residence		Student dormitory		21		84		20		80		P=1.000
		Private house		4		16		5		20
Interest in the nursing field		Very little		2		8		2		8		P=0.631
		Little		2		8		0		0
		Average		7		28		11		44
		A lot		9		36		7		28
		Very much		5		20		5		20
Clinical work experience		Yes		2		8		1		4		P=1.000
		No		23		92		24		96
Internship department		Special Sections		6		24		4		16		P=0.725
		General Sections		19		76		21		84

The mean and standard deviation of medication error occurrence among the participants were 67.04 ± 11.12, indicating a moderate level. Study findings revealed no significant difference in the mean occurrence of medication errors between the intervention and control groups before the intervention (P = 0.421). However, after the intervention, a statistically significant difference emerged (P < 0.05, Table 2).

Table 2.

Comparison of the mean score of medication error occurrence between intervention and control groups in nursing students before and after the intervention

Group		Stage		Intervention		Control		P
Variable				Mean (SD)		Mean (SD)
Medication error occurrence		Pre-test		65.760 (9.752)		68.320 (12.412)		t=0.811 P=0.421
		Post-test		56.760 (13.693)		66.280 (18.948)		t=2.036 P=0.047
Test, value, df, P value				t=4.474 P=0.000		t=1.115 P=0.276

SD=Standard deviation, df=degree of freedom

The results demonstrated that the mean occurrence of medication errors in the intervention group significantly decreased following the peer-led educational program (P < 0.0001), whereas no significant change was observed in the control group (P = 0.276, Table 2).

Discussion

The purpose of this study was to investigate how peer-assisted clinical pharmacotherapy education affected the prevalence of medication mistakes among nursing undergraduates. The results of this study’s peer-led teaching have been contrasted with those of related earlier research. The groups were homogenous in terms of medication mistake incidence before the intervention, as evidenced by the lack of a significant difference in the mean occurrence of medication errors between the intervention and control groups. Before the intervention, the average number of medication mistakes among nursing students was moderate (67.04 ± 11.12).

The findings of Hakim and Soroosh[22] revealed that 75% of nursing instructors had witnessed at least one medication error by nursing students, while 48.75% of nursing students admitted to committing medication errors more than once. Similarly, the study by Sabagh et al.[23] reported that 77.2% of nursing students acknowledged having made medication errors.

In the present study, following the intervention and the implementation of the peer-assisted learning method, the medication error occurrence scores in the intervention group decreased significantly. The findings also revealed that the medication error scores in the intervention group were markedly lower than those in the control group. These results align with several interventional studies that emphasize the importance of various teaching methods and their impact on reducing medication errors in nursing students.

According to Noohi et al.,[24] the intervention group’s mean medication performance ratings were considerably higher than those of the control group when a mobile-based drug application was combined with traditional bedside teaching. According to instructors’ perspectives, Hakim and Soroosh’s[22] study found that the main reason for medication mistakes is a lack of drug knowledge. As a means of reducing errors, the study recommended that clinical rotations include more time dedicated to reinforcing drug-related information and calculations. Similarly, Khalili et al.[10] discovered that students’ medication mistakes were mostly caused by a lack of pharmacological understanding.

The study by Pourteimour and Jasemi[25] indicated an improvement in attitudes and performance of nursing students in preventing pediatric medication errors after e-learning interventions. Shahzeidi et al.[26] reported that motivational training and problem-solving scenario-based methods could enhance medication safety among undergraduate nursing student. Salami[27] emphasized the necessity of implementing effective drug education programs within undergraduate nursing curricula and advocated for continuous monitoring and reinforcement. Deswal et al.’s[28] findings also supported the efficacy of targeted training in reducing medication errors among nursing students.

The combined outcomes of previous studies, which are in line with the current study’s findings, highlight the critical training needs of nursing students with regard to drug knowledge and its use in clinical settings. To improve the standard of clinical education and nursing care, they also stress the significance of implementing cutting-edge teaching strategies and technological advancements. Numerous research’ findings also demonstrate how peer-assisted learning improves nursing students’ clinical competence across a range of domains. In nursing education, Afaghi et al. and Hajihosseini et al.[29,30] stressed the value of using senior students to instruct their junior classmates. According to Sayed's research, peer teaching is an excellent way to increase nursing students’ performance, skill development, and educational empowerment in practical nursing education.[31]

Lee and Quinn[32] suggested that, considering the limited availability of simulation equipment, advanced technological tools, and online learning resources in all nursing programs, educators should consider implementing educational interventions such as peer-assisted learning to enhance medication-related competencies in nursing students.

In a study by Ravanipour et al.,[33] nursing students reported greater satisfaction with peer learning compared to conventional teaching methods. Consequently, peer learning was recommended as a beneficial method for nursing students to practice educational leadership and develop clinical skills. Similarly, Dehghani et al.[34] advocated for the application of this method in clinical education for nursing students and other medical science disciplines.

Limitation and recommendation

Due to the limited sample size of senior undergraduate nursing students in this study, future studies with larger sample sizes are recommended. These studies should explore the application of various innovative educational methods across different groups of medical science students.

Conclusion

The findings of the present study, along with other similar research, suggest that peer-assisted learning is an effective educational intervention for health sciences students, particularly in clinical settings. It is recommended that additional interventions using this novel educational approach on larger and more diverse samples be conducted.

Ethics approval

The study was approved by Ethics Committee of Aja University of Medical Sciences (IR.AJAUMS.REC.1402.104). Informed consent was obtained from all participants. The study was carried out according to the ethical principles of the World Medical Association’s Declaration of Helsinki.

Author’s contributions

All authors participated in data analysis, preparing the initial version and revising the article. Finally, all of them approved the final version for publication. The manuscript has been read and approved by all the authors.

Conflicts of interest

The authors have no conflict of interest in this work.

Funding Statement

Nil.