Nurse Education Today 93 (2020) 104540

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Nurse Education Today

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Undergraduate nursing students' pharmacology knowledge and risk of error T

estimate
Meriam Caboral-Stevensa, , Rosalinda V. Ignaciob, Gerald Newberrya
⁎

a
School of Nursing, Eastern Michigan University, United States of America
b
Department of Psychiatry, University of Michigan, United States of America

ARTICLE INFO ABSTRACT

Keywords: Background: In the United States alone, medication error causes injury to approximately 1.3 million people
Pharmacology knowledge every year. Frequently, nurses have been blamed for the high rates of medication administration errors. Factors
Risk of error associated with medication error by nurses are categorized as personal, contextual and knowledge-based. There
Self-rated certainty is evidence in the literature that showed nurses have insufficient knowledge in pharmacology.
Undergraduate nursing students
Purpose: The overall purpose of this study was to estimate the risk of error based on the combined scores on
pharmacology knowledge and self-rated certainty scores of undergraduate nursing students.
Method: A cross-sectional and correlational study was conducted. Students enrolled in an undergraduate nursing
program who completed or were currently taking the pharmacology course were eligible for the study. Based on
power analysis, a sample of 156 students was needed to reach 80% power with a level of significance of 0.05. A
42-item Pharmacology Knowledge Questionnaire (PKQ) test was administered, and students were asked to
provide their level of certainty for each of their answers. Risk of error was calculated based on the combined
scores in PKQ and self-rated certainty scores.
Results: 147 nursing students, 83% females with a mean age of 24 (SD = 5) years, participated in the study.
Mean score in the PKQ was 25 (SD = 3.51) out of 42 items, which is equivalent to a grade of 60% (with a
calculated weighted mean grade of 56%). Drug calculation was the subject area where students had the lowest
mean score. Mean overall risk of error for all 42 items in the PKQ was 1.7 (SD = 0.14), on a scale of 0–3. This
means that, on average, high risk of error was noted in 14% of the students who rated incorrect answers with
high certainty. Positive correlations were noted between age and pharmacology score, and between when
pharmacology course was last taken and risk of error. A negative correlation was noted between when phar-
macology course was last taken and pharmacology score.

In the United States (U.S.) alone, medication error causes injury to
an estimated 1.3 million people every year (U.S. Food and Drug
Administration [FDA], 2016). This translates to at least one death every
day (U.S. FDA, 2016). The estimated total cost of preventable medi-
cation error is $16 billion annually (NEHI, n.d.). Medication error is
defined as an error, either through omission or commission, at any step
along the pathway that begins when a clinician prescribes a medication
and ends when the patient receives the medication (U.S. Dept. of Health
and Human Services/Agency for Healthcare Research and Quality,
2015). Medication error is also a disruption in the treatment process,
which leads to a potential or actual risk of hazard for patients. Medi-
cation administration is complex and involves a multi-step process in-
volving prescribing, transcribing, dispensing, administering of drugs
and monitoring of patients' responses (Anderson, 2011). Although an
error may occur at any stage, administration error accounts for 26% to
32% of total medication error (Anderson, 2011). Nurses play a vital role
because they are responsible for administering medications in hospitals.
1. Nurses and medication error
Frequently, nurses have been blamed for the high rates of medica-
tion administration errors in health care (Wright, 2013). A previous
study reported that the mean incidence of medication error for each
nurse ranged from 2.2 to 7.4 (Cheragi et al., 2013). This variability
could be attributed to fear of reporting medication error or near misses
by practicing nurses (Cheragi et al., 2013). Some identified factors that
may contribute to medication errors made by nurses include medication
miscalculations, lack of knowledge and proficiency, extreme tiredness,

⁎
Corresponding author at: 310 Marshall Bldg., 100B Porter Bldg., Center for Health Disparities, Innovations and Studies, Eastern Michigan University, Ypsilanti, MI
48197, United States of America.
E-mail address: msteve37@emich.edu (M. Caboral-Stevens).

https://doi.org/10.1016/j.nedt.2020.104540
Received 25 July 2019; Received in revised form 1 June 2020; Accepted 14 July 2020
0260-6917/ © 2020 Elsevier Ltd. All rights reserved.
M. Caboral-Stevens, et al.
inadequate work experience, and negligence of hospital protocol due to
lack of time (Carlton and Blegen, 2006). Hand and Berger (2008) ca-
tegorized medication error into personal, contextual and knowledge-
based factors. Personal factors include tiredness, stress, lack of con-
fidence to question physician's orders, lack of concentration, compla-
cency, and other personal variables. Contextual factors include lack of
training, short staffing, heavy workloads, and distractions. Lastly,
knowledge-based factors include experience of the nurses and their
knowledge of medications or drugs and disease, and mathematical
calculation. Even though the all three factors are of similar importance,
the focus of this study is on the knowledge-based factors.
2. Nurses' knowledge in pharmacology
There is evidence in the literature that showed nurses have in-
sufficient knowledge in pharmacology, not just in the U.S. but globally
(Cheragi et al., 2013; Carlton and Blegen, 2006; McMullan et al., 2010).
Inadequate pharmacology knowledge was reported as one of the human
factors associated with medication error (Cheragi et al., 2013). How-
ever, there is very limited research connecting the risk of error com-
mitted by nurses with their knowledge of pharmacology. To date, the
two studies by Simonsen et al. (2011, 2014) are the only studies that
have analyzed nurses' pharmacology knowledge and self-rated certainty
to estimate their risk of error. In their earlier study of 203 practicing
nurses, they reported that nurses have unsatisfactory medication
knowledge with significant risk for medication error (Simonsen et al.,
2011). Their subsequent study, comparing 446 senior student nurses
and experienced nurses, showed that experienced nurses have sig-
nificantly superior medication knowledge than the students, but,
nevertheless, both groups of nurses showed insufficient medication
knowledge (Simonsen et al., 2014). Drug management and drug cal-
culation were the two areas of differences between student nurses and
experienced nurses. In addition, a low risk of error was associated with
high knowledge (Simonsen et al., 2014). Since these two studies were
conducted in Norway, it was the desire of the researchers to replicate
this study among U.S. nurses.
3. Purposes and hypothesis
The overall purpose of this study was to estimate the risk of error of
undergraduate nursing students based on their combined scores on the
Pharmacology Knowledge Questionnaire (PKQ) and their self-rated
certainty. The secondary aims were to determine the relationship be-
tween demographic characteristics and pharmacology score and be-
tween demographic characteristics and risk of error. This study hy-
pothesized that there is correlation between pharmacology score, age,
when pharmacology was last taken, and risk of error.
4. Theoretical framework
The Swiss Cheese Model by Reason (2000) was used to guide this
study. The model explains how failures within a complex and layered
healthcare system occurs. At the system's level, there are barriers in
place to prevent hazards which may cause harm to a patient. However,
just like the Swiss cheese there are holes, which represents opportu-
nities for a process to fail. When by chance all the holes are aligned, the
hazard reaches the patient and causes harm or bad outcome (Perneger,
2005). In this study, holes represent human factor, which are the
nurses. The human factor focuses on the unsafe acts of the nurse, which
is medication error. In the present study, we looked at the nurse's
knowledge of pharmacology as the cause of this unsafe act by the nurse.
2
Nurse Education Today 93 (2020) 104540
5. Method
5.1. Design
The study was a cross-sectional and correlational study of a sample
of students in the nursing school of a small university in the U.S.
Midwest conducted from fall 2017 to summer 2018. Eligible students
were asked to complete a short demographic worksheet, take a paper
and pencil pharmacology test, and complete the certainty section in-
cluded in the test. Results of the pharmacology exam were not shared
with the student participants. No grade or extra credit was assigned to
students who participated in this research study.
5.2. Sample and setting
Students registered in one of the undergraduate nursing programs
were recruited to participate in the study through flyers posted
throughout the university and by asking faculty members teaching
undergraduate courses to distribute flyers in their classes. Students who
were willing to participate were asked to contact any of the principal
investigators (PIs) to schedule a meeting to complete the test. Students
were eligible to participate in the study if they were registered in one of
the undergraduate nursing program at the lead author's institution and
had completed or were currently taking the pharmacology course. A
sample of 156 students was needed based on the power analysis to
reach 80% power with a level of significance of 0.05.
5.3. Ethical consideration
Institutional Review Board approval was obtained from the lead PI's
institution. Informed consent was obtained from the student partici-
pants. Participation was voluntary and anonymous.
5.4. Instruments
5.4.1. Pharmacology Knowledge Questionnaire (PKQ)
This 42-item multiple choice and fill-in the blanks questionnaire by
Simonsen et al. (2011) was modified, with permission, and used to
assess pharmacology knowledge of nursing students on three major
pharmacology areas. The pharmacology areas and the contents in-
cluded were 1) Pharmacology: general pharmacology, effects, side ef-
fects, administrations, interactions, and generic drugs; 2) Drug man-
agement: storage, dispensation, and administration; and 3) Drug dose
calculation: conversion of units, formulas for calculation of dose,
quantity or strength, and infusion and dilutions. The maximum time to
complete the test was 1½ hour.
The modified PKQ was reviewed for face and content validity by
three doctoral-prepared nurse educators who were teaching in the un-
dergraduate program and with experience in teaching pharmacology
courses and writing test questions. Polit and Beck's (2012) content va-
lidity (CV) estimation for relevance was used to assess the CV for re-
levance and clarity of the PKQ. The items' CV index (I-CVI) of the PKQ
was 0.96, which is above the 0.83 cut-off to be considered acceptable.
The PKQ scales CVI (S-CVI) was 0.95, considered acceptable based on
the criterion of 0.80 for lower limit of acceptability for S-CVI (Polit and
Beck, 2012).
5.4.2. Certainty
For each of the pharmacology question, students were asked to in-
dicate their self-rated certainty using a Likert scale graded from 0 (very
uncertain) to 3 (very certain). Students were instructed to give a grade
of 0 if they were very uncertain, a grade of 1 if they were relatively
uncertain, a grade of 2 if they were relatively certain, or a grade of 3 if
they were very certain about their answer in the specific PKQ question.
A score of 0 (very uncertain) indicated that the nurse would either seek
help or consult reference books and/or colleagues; whereas a grade of 1
M. Caboral-Stevens, et al. Nurse Education Today 93 (2020) 104540

(relative uncertainty) indicated that the nurse would probably seek help Table 1
or assistance. A grade of 2 (relative certainty) indicated that the nurse Demographic characteristics (N = 147).
would probably not seek help, while a grade of 3 (very certain) meant Characteristics N (%)
that the nurse would not seek help or assistance (Shawahna et al.,
2016). Age group
19–23 100 (69)
24–29 29 (20)
5.4.3. Risk of error estimate 30–35 11 (8)
The calculation for risk of error was based on Shawahna et al.'s 36 and older 6 (4)
(2016) study. According to Shawahna et al. (2016), risk of error esti- Gender
mate is manually calculated for each of the PKQ. This is done by Male 25 (17)
combining the PKQ answer and self-rated certainty, and individually Female 122 (83)
scoring the items from 1 (low risk of error estimate) to 3 (high risk of Race
error estimate). A score of 1 for low risk of error is assigned if the Asian 7 (4.8)
student's answer in PKQ is correct and their self-rated certainty grades Black/African-American 12 (8.0)
Caucasian/White 122 (84.4)
were 2 or 3 (relatively certain or very certain). A score of 2 for mod-
Pacific Islander 2 (1.4)
erate risk of error is assigned when the PKQ answer is correct and the Missing (did not respond) 2 (1.4)
self-rated certainty grades were 1 or 0 (low certainty or very un-
Marital status
certainty). Incorrect answers in PKQ combined with high certainty Single 64 (43.5)
grades (score of 2 or 3) were given a score of 3, indicating high risk for In a relationship 62 (42.2)
error. Incorrect answers in PKQ combined with low certainty scores 0 or Married 17 (11.6)
1 were given a risk of error score of 2, indicating moderate risk. Un- Divorce/Separated 4 (2.7)
answered questions were considered “incorrect answers”, and un- Place of birth
answered certainty scores were considered “very uncertain”. Born in U.S. 136 (92)
Born outside the U.S. 11 (8)

6. Data analysis Nursing program enrolled in

Traditional BSN 79 (54)
Accelerated 30 (20)
The Statistical Package for the Social Science (SPSS)® Version 25 Collaborative; 2 + 2 38 (26)
was used in performing statistical analysis. Descriptive statistics such as
When pharmacology course was taken?
means, frequencies, percentages, and standard deviations were used to
Currently 108 (74)
describe demographic characteristics, PKQ scores, certainty, and risk of Last six months 27 (18)
error of the students. A weighted mean percentage was calculated with At least one year ago 11 (8)
each of the PKQ content because of uneven question items in each Currently working in healthcare facility
subscale. Pearson's product-moment correlation and Spearman's rank Yes 76 (52)
correlations were used to determine the relationships between vari- No 68 (46)
ables. Missing data were coded separately. Missing 3 (2)

If so, do you administer medications? (N = 76)

7. Results Yes 15 (20)
No 56 (80)

7.1. Demographic characteristics

A total of 147 students participated in the study, nine students less
than the required sample size based on the power analysis. Students
who participated in the study were 83% females with a mean age of 24
(SD = 5) years. Ages ranged from 19 to 46 years, with the majority
(89%) younger than 30 years old; 84% were Caucasians, 92% were
born in the U.S., 54% were enrolled in the traditional Bachelor of
Science in Nursing (BSN) program, and 74% were taking the pharma-
cology course at the time of study. Fifty two percent of the student
participants were currently working in a healthcare facility and of
these, 20% administered medication in their workplace (Table 1).
7.2. Pharmacology knowledge and certainty score
The overall mean score in the PKQ was 25 (SD = 3.51) out of 42
items, which is equivalent to a grade of 60%. However, after calculating
the weighted mean of all the PKQ content, the overall PKQ grade was
56%. The lowest score was 17 correct answers out of 42 (40%), and the
highest was 35 (83%). Only 10% (n = 15) of the students had an
overall grade of 70% or above in the PKQ. The scores in each of the PKQ
contents, namely pharmacology, data management, and drug calcula-
tions, were 11 (SD = 1.87) out 18 items (61%), 6.2 (SD = 1.29) out of
10 items (62%), and 7.7 (SD = 2.06) out of 14 items (55%), respec-
tively. Table 2 also presents the self-rated certainty scores of students
and the calculated risk of error for the overall PKQ and by the three
major pharmacology content areas. The mean certainty scores for the
three content areas of the PKQ was 1.7 (SD = 0.44), with drug
management having the lowest mean certainty score at 1.5 (SD = 0.45)
compared to the other content areas, pharmacology with a mean cer-
tainty score of 1.8 (SD = 0.46) and drug calculations with a mean
certainty score of 1.8 (SD = 0.66).
7.3. Risk of error
The mean overall risk of error for all 42 items in the PKQ was 1.7
(SD = 0.14) on the scale of 0–3 (Table 2). Table 3 presents the calcu-
lated weighted mean of correct answers in each of the pharmacology
content and the calculated risk of error for each question. About 42% of
the students correctly answered the question and were very certain of
their answer (low risk), 14% of the students who answered the question
incorrectly were very certain of their answer (high risk), while 44% of
the students either answered the question correctly or incorrectly and
were uncertain of their answer (moderate risk).
7.4. Relationships among variables
Positive correlations were noted between age and pharmacology
percent score (r = 0.173, p = 0.036), and between when a pharma-
cology course was last taken and risk of error (r = 0.573, p = 0.01).
Age and risk of error had a negative correlation, though not significant
(r = −0.162, p = 0.051). On the other hand, a significant negative
correlation was seen between the pharmacology percent score and
when pharmacology course was last taken (r = −0.602, p = 0.01).

3
M. Caboral-Stevens, et al. Nurse Education Today 93 (2020) 104540

Table 2
Primary outcomes of the PKQ test in pharmacology knowledge, certainty score, and risk of error.
Pharmacology knowledge score mean (SD) Certainty score (0–3) Mean (SD) Risk of error (0–3) Mean (SD)

Overall score (42 items) 25 (3.51) 1.7 (0.44) 1.7 (0.14)

Pharmacology score (18 items) 11 (1.87) 1.8 (0.46) 1.7 (0.18)
Drug management score (10 items) 6.2 (1.29) 1.5 (0.45) 1.7 (0.18)
Drug calculation score (14 items) 7.7 (2.06) 1.8 (0.66) 1.7 (0.21)

This negative correlation persisted even after selecting only those who
administers medication at work (r = −0.573, p = 0.26).
8. Discussion
Findings from this study showed that undergraduate nursing stu-
dents have insufficient knowledge in pharmacology with evidence of
increased risk of error. Nursing students in this present study had an
overall grade of 60% in the PKQ. This pharmacology score was similar
with other nursing students' pharmacology test scores worldwide (Dilles
et al., 2011; Heczkova and Bulava, 2018; Watkins and Carr, 2018). The
current study also showed that student's potential risk of error was high,
based upon 14% of students who were very certain that their incorrect
answers were correct. This high risk of error score is consistent with
Simonsen et al.'s (2014) study of registered nurses with an overall 15%
high risk of error. The present study provides additional support for the
inadequate of knowledge in pharmacology among nursing students and
the need to better prepare undergraduate nursing students to develop
medication competence skills. According to Sulosaari et al. (2015) there
are three interconnected components of medication competence - the-
oretical, practical and decision making. Medication competence begins
with a solid theoretical base of pharmacology (Sulosaari et al., 2015).
With this knowledge base, student nurses must also be able to apply this
them into actual clinical situations. Having both sound theoretical base
and practical competence, it enables students to make clinical decisions
with regards to a patient's treatment regimen (Sulosaari et al., 2015).
Another important aspect of medication competence is numeracy skills.
Numeracy skills are essential for nurses to be able to correctly calculate
medication doses. There is evidence that drug calculation is a major
challenge for nursing students (Bagnasco et al., 2006; Eastwood, Boyle,
Williams, & Fairhall, 2011; Mackie and Bruce, 2016). Interestingly,
deficiency in numeracy skills is not isolated to nursing but is also seen
among other health care students, including paramedic students
(Eastwood et al., 2013), pediatric residents (Glover and Sussmane,
2002), and doctors (Oldridge et al., 2004). Deficiency in both phar-
macology knowledge and numeracy skills among nursing students is
very worrisome because of the potential detrimental effect to patient
safety and can impact patient outcomes. This is even more important to
address now as several nursing schools have a program track that ac-
celerate students from a baccalaureate to an advanced doctoral degree.
Medication competence is critical as these advance practice nurses will
be in a prescribing role after graduating. The above findings supported
the Swiss Cheese model's explanation about the hazards (holes) within a
complex system; in this study the human factor. The student's weak
knowledge base in pharmacology and numeracy skills may represent
the hazard that may reach the patient causing bad outcome.
The present study also showed correlations between when phar-
macology course was last taken and risk of error, and between phar-
macology score and when a pharmacology course was last taken. This
means that the longer time since the nursing student had taken a
pharmacology course, the lower their pharmacology scores and the
higher their risk of error. At the time of their participation in this study,
about 2% of the students reported it had been one year and longer since
they had taken a pharmacology course. This result is consistent with
Simonsen et al.'s (2011) study which showed previous pharmacology
courses had low association with high knowledge in pharmacology,
drug management, and drug calculation. However, effect could not be
determined because of limited information. These relationships are
important to note as they suggest that nursing students may have
problem with long-retention of knowledge previously learned. Nurse
educators may need to review their curriculum to ensure that phar-
macology contents are being incorporated throughout. Similarly, this

Table 3
Proportion of students with correct answers on each of the PKQ content, and the risk of error calculated for each of the PKQ contents.
Proportion of all students (n = 147)

Itemized pharmacology questionnaire content Proportion of students with correct answers (SD) Low riskb Moderate riskc High riskd

Pharmacology (18-items) 63a (26.2) 44 41 15

General knowledge (3 items) 66 (17.1) 59 15 26
Effects (4 items) 48 (19.4) 30 59 11
Side effects (4 items) 62 (23.8) 38 50 12
Interactions (2 items) 78 (28.7) 51 39 10
Administration (2 items) 43 (30.2) 27.5 35 37.5
Synonymous name/generic (3 items) 84 (21) 59 37 4
Data management (10-items) 62a (24.3) 38 53 10
Liability (1item) 99 (11.6) 92 7 1
Storage (2 items) 68 (26.7) 98 48.5 3
Durability (4 items) 56 (23.5) 48.5 58 13
Administration (3 items) 54 (29.4) 29 63 13
Data calculation (14-items) 44a (41.6) 42 43 15
Dose-quantity strength (6 items) 66.6 (18.4) 49 41 10
Conversion (3 items) 25.9 (22.5) 65 21 14
Infusion/dilution (5 items) 59.2 (17.0) 20 58 22
Overall percentage 56a (31.5) 42 44 14

a
Weighted mean in the overall and three pharmacology contents.
b
Low risk – proportion of students who answered a question correctly and were very uncertain of their answer.
c
Moderate risk –proportion of students who answered the questions either correctly or incorrectly but were uncertain of their answer.
d
High risk –proportion of students who answered a question incorrectly and were very certain that their answer is correct.

4
M. Caboral-Stevens, et al.
further suggests the need to continuously evaluate student's knowledge
of pharmacology throughout.
This study utilized the PKQ from the Simonsen et al. (2011) study
that was adapted and modified. To date, no standardized or validated
PKQ tool is available for researchers to assess pharmacology knowl-
edge. Most researchers in other studies have developed their own
pharmacology questionnaires.
The study acknowledges several limitations. It was conducted in
only one university from a convenience sample of undergraduate stu-
dents; hence generalization is limited. The study did not reach the
sample size calculated in power analysis. Students who participated did
not receive any extra credit on their grades or compensations for taking
the PKQ. This lack of pressure may have made the students careless or
less vigilant in answering the questions, hence their score may have
been affected. Their performance on the test score might be improved
by associating this pharmacology test with a grade or credit. In addi-
tion, students' voluntary participation to take this test may have biased
the results. It may be possible that students who were confident in their
pharmacology knowledge were the ones who participated, suggesting
that the potential lack of pharmacology knowledge among under-
graduate students might be greater than that suggested in the results of
this study. The times and places of administration of the PKQ were not
consistent among the students. Some students took the exam depending
on the researcher's availability to administer the test while others took
it at the end of their class, which was mostly in the evenings. Most of
these students take classes in the evening after coming from their
clinical areas, hence, the students may have been too physically and
mentally fatigued by the end of their class to really concentrate on the
tests. In regards to the testing location, factors including noise and
lighting may have affected their responses on the test.
This study has implications to nursing education, practice, policy,
and research. Nurse educators may need to re-evaluate the curriculum
to identify ways to increase mathematical or numeracy skills of nursing
students as the biggest part of a nurse's work is medication adminis-
tration, which includes calculating medication dosages. Likewise, nur-
sing schools may want to start looking carefully on numeracy skills of
the nursing student candidates and including some mathematical
courses as part of the admission requirements. Nursing research is much
needed to determine what teaching pedagogy will better enhance nu-
meracy skills among students and nurses who recently graduated.
Nursing education and research lack the definition of medication
competence that incorporates pharmacology knowledge. From a nur-
sing practice perspective, medication administration is one of the fun-
damental roles of a nurse. Pharmacology knowledge of nurses may need
to be part of ongoing competency evaluation in nursing practice. To do
this, policy may need to be changed to require practicing nurses to take
a refresher course in pharmacology calculation before renewing their
nursing license. Further research is needed to replicate this study in a
controlled environment or simulated clinical scenario to further de-
termine whether the scores will be similar.
9. Conclusion
In summary, this study presented an innovative way to evaluate
patient safety through pharmacology knowledge risk of error estima-
tion. Nursing students in the study had an estimated moderate to high
risk of error. There is a need to augment students' training in phar-
macology knowledge, and to enhance students' numeracy and mathe-
matical skills necessary for drug calculation. Further research is needed
to more accurately estimate pharmacology knowledge and risk of error
among nursing students, and nurses in general.
Author statement
Caboral-Stevens – conceptualization, funding acquisition, metho-
dology, supervision, writing original draft,
5
Nurse Education Today 93 (2020) 104540
Ignacio – validation, formal analysis, editing,
Newberry – conceptualization, project administration, visualiza-
tion, writing and review.
Declaration of competing interest
None declared.
Acknowledgment
Lead author received internal award (Summer Research/Creative
Award) from Eastern Michigan University for this research activity. We
also would like to acknowledge Laura Kovick, from the Writing Center
at Eastern Michigan University for reviewing the manuscript thor-
oughly.
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