Wennberg‑Capellades et al.

BMC Nursing (2022) 21:309

https://doi.org/10.1186/s12912-022-01085-9

RESEARCH Open Access

Where do nursing students make mistakes

when calculating drug doses? A retrospective
study
Laia Wennberg‑Capellades* , Pilar Fuster‑Linares , Encarnación Rodríguez‑Higueras ,
Alberto Gallart Fernández‑Puebla   and Mireia Llaurado‑Serra   

Abstract
Background: Research internationally shows that nursing students find dosage calculation difficult. Identifying the
specific aspects of dose calculation procedures that are most commonly associated with errors would enable teach‑
ing to be targeted where it is most needed, thus improving students’ calculation skills. The aim of this study was to
analyze where specifically nursing students make mistakes when calculating drug doses.
Method: Retrospective analysis of written examination papers including dosage calculation exercises from years 1,
2, and 3 of a nursing degree program. Exercises were analyzed for errors in relation to 23 agreed categories reflecting
different kinds of calculation or steps in the calculation process. We conducted a descriptive and bivariate analysis of
results, examining the relationship between the presence of errors and the proportion of correct and incorrect final
answers.
Results: A total of 285 exam papers including 1034 calculation exercises were reviewed. After excluding those that
had been left blank, a total of 863 exercises were analyzed in detail. A correct answer was given in 455 exercises
(52.7%), although this varied enormously depending on the type of exercise: 89.2% of basic dose calculations were
correct, compared with just 2.9% of those involving consideration of maximum concentration. The most common
errors were related to unit conversion, more complex concepts such as maximum concentration and minimum dilu‑
tion, or failure to contextualize the answer to the clinical case. Other frequent errors involved not extracting the key
information from the question, not including the units when giving their answer, and not understanding the ques‑
tion. In general, fewer errors in basic dose calculations were made by students at later stages of the degree program.
Conclusions: Students struggle with more complex dose calculations. The main errors detected were related to
understanding the task and the key concepts involved, as well as not following the correct steps when solving the
problem.
Keywords: Dosage calculation, Nurse education, Medication errors, Nursing students, Patient safety

Background
Dosage calculation errors can have serious consequences
when administering medicines, and hence numeracy
skills are crucial for ensuring safe medication manage-
*Correspondence: [email protected] ment [1]. A study by Ross et al. [2] in a pediatric teaching
Department of Nursing, School of Medicine and Health Sciences, Universitat hospital found that 8% of medication incidents involved
Internacional de Catalunya, Josep Trueta s/n, 08195 Barcelona, Sant Cugat del a tenfold error in the dose administered. More recently,
Vallès, Spain

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Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 2 of 11

a systematic review of intravenous admixture drug Another issue to consider, and one highlighted in a
preparation errors found that the reported incidence of recent comparative study of six European countries [5],
wrong doses across the studies reviewed ranged from 0 concerns cross-national differences in medication edu-
to 32.6%, while for wrong diluent volume the range was cation regulations and practices and the competences
0.06 to 49.0%. The authors highlighted the need in future that graduating nurses are expected to have acquired.
research to develop standardized definitions for these For instance, some professional bodies such as the UK
types of errors so as to facilitate a better understanding of Nursing & Midwifery Council recommend that nurse
where they happen within the drug preparation process education institutions should require students to achieve
and to devise ways of avoiding them [3]. This underlines a 100% pass on a health numeracy assessment includ-
an issue raised by other authors, namely that it is difficult ing calculation of medicines [14]. In our country, Spain,
to know whether an error in the final dose administered a strict criterion such as this is not applied within nurse
is due solely or primarily to miscalculation, insofar as it education programs, although safe medication manage-
may be the result of an error further back in the process, ment is considered a key competence for students to
such as pharmacy mislabeling or incorrect or unclear acquire during their pre-registration university training
prescribing [2]. [15].
Research focusing on nursing students suggests they Whatever the requirements and approach to training, it
often have poor drug calculation skills, due especially is vital that nursing students acquire adequate numeracy
to difficulties with understanding mathematical prin- skills, as once they enter professional practice they will
ciples [4]. Accordingly, although they are usually able be responsible for administering medication. The impor-
to perform simple calculations, they struggle with tasks tance of their becoming proficient in this respect by the
involving multiple steps and which require a higher time they graduate is underlined by research suggesting
level of conceptual knowledge [5]. A further issue con- that difficulties with drug calculation often persist among
cerns the extent to which nursing students are aware of registered nurses [16–18]. From the perspective of nurse
their errors. In this regard, a recent study in which stu- education, therefore, it is crucial to identify where stu-
dents were asked to indicate their level of certainty about dents struggle the most when it comes to dosage calcu-
answers given to a pharmacology knowledge question- lation. Despite this, few studies have examined in detail
naire concluded that there was a high risk of medication the specific aspects of the drug calculation process where
administration error in 14% of the students who rated students make mistakes [7, 19–21].
incorrect answers with high certainty [6]. Given that the dose calculation skills of both student
Aside from their arithmetic skills, there are a number and registered nurses is an issue of international concern,
of other factors that may contribute to nursing students’ and one that has implications for patient safety, our aim
difficulties with dose calculation. One of these is math in the present study was to conduct an in-depth analy-
anxiety, which can undermine their ability to understand sis of the kinds of errors that undergraduate nursing stu-
and complete tasks involving mathematics [7]. A fear of dents make when performing dose calculation exercises.
math, resulting in resistance to learning math for medi- Identifying the specific aspects or steps in the process
cation administration, has also been noted in research they find most difficult would enable nurse educators to
using focus groups to explore students’ own perspectives target teaching where it is most needed.
on learning math for medication calculation [8]. Other
themes that emerged in the same study were: resentment Method
among students towards what they perceive as ‘compli- Design
cated’ math; lack of confidence among students leading This was a descriptive retrospective study in which we
to a fear of error in clinical practice; a recognition among reviewed all the examination papers that included at
students that they need to be more self-directed in devel- least one dose calculation exercise and which had been
oping their math skills; and the need for clinical instruc- submitted over two academic years (2017-18 and 2018-
tors to be consistent in giving students the opportunity to 19) by students from years 1, 2, and 3 of a nursing degree
practice calculations in the clinical setting [8]. program at our university.
Notwithstanding the difficulties that students experi-
ence with dose calculation, the literature suggests that Setting
the problem is far from unsurmountable. Indeed, vari- In Spain, nursing degrees last 4 years, and successful
ous studies have reported the effectiveness of workshops graduates are eligible to perform independently oral and
or web-based platforms designed to support students’ higher risk medication management, including intrave-
learning and improve their medication calculation skills nous injections and infusions [15]. Nursing students at
[9–13]. our university begin to be taught dose calculation and
Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 3 of 11

medication administration in year one of the degree pro- and consisted of 10 questions of varying difficulty and
gram. This is done through both theory classes and low- complexity. This part of the exam had been purposely
fidelity simulation, totaling 6 hours. At this stage of their designed to include some calculation exercises that went
training, students learn how to administer medication beyond the level required of year 2 students, and thus
through different routes (e.g., oral, IV) and to make sim- they would not necessarily be expected to answer them
ple dose calculations on paper (exercises such as “Basic all correctly (exercises 7, 8, and 9 in the Year 2 block of
dose calculation” or, “Infusion rate”; see Supplementary Table 1). The rationale for including more difficult prob-
material 1 for definitions). In year 2, students attend a lems was that we would then be able to track the progress
2-hour theory class in which they are required to per- of individual students by setting them the same questions
form the same exercises as in year 1, as well as new types (changing only the numerical values involved) in years 3
of calculation such as “Unit conversion”, “Dose accord- and 4 of their studies (the questionnaire used is shown in
ing to patient’s weight”, and “Dose calculation involving a Supplementary material 2). This progress monitoring is
percentage”. In year 3, theory classes and low-fidelity sim- not part of the present analysis. Finally, the exercises cor-
ulation (totaling 16 hours) are used to provide students responding to year 3 formed part of an ordinary written
with further practice in the aforementioned types of cal- exam and of an OSCE. Table 1 summarizes the exercises
culation exercise and different routes of drug administra- used in each of the 3 years; further details, with exam-
tion, this time incorporating more advanced aspects such ples, are given in Supplementary material 3.
as the use of infusion pumps. In year 4, students do not
receive classroom instruction in dose calculation or med- Procedure
ication administration as the year is spent almost entirely In a first step, we selected a random sample of papers
on clinical placement. covering all the different exams. In the absence of an
Students begin clinical placements in year 1 of the existing rubric for classifying errors, two members of
degree program, following completion of all the theory the research team, working independently, then car-
classes. Over the 4 years of their studies, they complete ried out an initial content analysis in order to catego-
a total of 2300 hours on placement. Because students rize the different types of error made by students in
are assigned to different clinical settings, the experience each exercise. This provisional set of categories was
they gain in relation to dose calculation and medication then agreed with the rest of the team and checked for
administration may vary. clarity and relevance by asking each team member to
apply it to a small sample of exam papers. This pro-
Examination papers reviewed cess yielded a consensus list of 23 categories that were
All the examinations reviewed were time limited and had used to analyze the total sample of papers (see Sup-
been sat in the presence of an invigilator, subsequent to plementary material 3). For this final analysis, and
having received the instruction corresponding to each given the large number of records, the exam papers
course year (see Setting). For year 1 students, the dose were distributed among pairs of researchers, who first
calculation exercise formed part of a written station of reviewed them individually before comparing and dis-
an objective structured clinical examination (OSCE). The cussing their evaluation with that of the co-evaluator
calculation exercises in year 2 were part of a written exam so as to reach a consensus decision. The task in each

Table 1 Types of exercises included in the analysis

Year 1 Clinical case of an adult patient in which students must calculate the dose of a prescribed drug from the stock available. They also have to
calculate the rate at which the drug should be administered.
Year 2 Written exam comprising 10 calculation exercises, as follows:
1) Unit equivalences (theoretical); 2 and 3) basic dose calculations; 4) calculation requiring unit conversion; 5) dose calculation involving a per‑
centage; 6) dose according to patient’s weight; 7) drug concentration over time; 8) total infusion time, taking into account the maximum flow
rate; 9) volume of diluent, taking into account the maximum concentration; 10) infusion rate.
Exercises 6, 8, and 9 referred to a pediatric patient, while the remainder concerned adults. With the exception of exercise 1, all the questions
were formulated using standard technical language.
Year 3 Four exercises distributed across two exams:
Clinical case of an adult critical patient: 1) the calculation involves maintaining a prescribed IV dose for a different drug concentration and infu‑
sion rate.
Clinical pediatric cases: 2) calculation of IV dose based on patient’s weight and with unit conversion, plus calculation of infusion rate; 3) calcula‑
tion of oral medication based on patient’s weight; 4) calculation of IV dose based on patient’s weight and with unit conversion, plus calculation
of infusion rate and concentration.
Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 4 of 11

case was to record 1) whether the category was appli- However, we also analyzed the individual results for each
cable or not to a particular exercise, and 2) whether exercise.
the student’s answer took into account the aspect
referred to by the category, and if so whether they did Ethical considerations
so correctly, partially or incorrectly. At this stage in Approval for the study was granted by both the Depart-
the process, papers were coded so that only the evalu- ment of Nursing and the Research Ethics Committee of
ator knew the identity of the student. The results of the Universitat Internacional de Catalunya (ref. INF-2018-
this analysis were recorded using a spreadsheet, which 05). The need for informed consent was waived by the eth-
was then reviewed by the principal investigator (PI) to ics committee due to the retrospective nature of the study
check for any inconsistencies or errors (e.g., the cat- (see Procedure section). All methods were carried out in
egory regarding unit conversion was wrongly recorded accordance with relevant guidelines and regulations.
as being applicable to an exercise that did not require In preparing the present article, we referred to the
this calculation); in the event that a problem was iden- STROBE checklist of items that should be included in
tified, the PI asked the evaluator who had reviewed reports of descriptive retrospective studies [22].
the corresponding exam paper to make the necessary
correction(s) to the database. Once the accuracy of
the database had been checked, its contents were fully Results
anonymized by deleting the aforementioned codes. We reviewed 285 examination papers that included 1034
calculation exercises. After excluding those exercises
Data analysis that had been left blank (n = 171), a total of 863 exercises
Any exercises that were left blank and had not been were analyzed. Table 2 shows the number of exercises
attempted by the student were excluded. For the reviewed and analyzed for each of the three course years.
descriptive analysis we calculated absolute and rela- Of the exercises analyzed, 455 (52.7%) were answered
tive frequencies, and where appropriate the mean and correctly. Table 3 shows the number of each type of
standard deviation. Bivariate analysis using either the exercise that were attempted and the number that were
chi-square or Fisher’s exact test, as appropriate, was correct. Overall, a correct answer was given in 28.4%
then conducted to examine whether there were sig- of the clinical case exercises in year 1, in 50.9% of the
nificant differences between the proportion of cor- exercises in year 2 (mean score of 5.2 (SD 2.2) out of
rect and incorrect answers depending on the presence 10), and in 41.8% of those in year 3. The mean score
of errors in each of the aspects (categories) analyzed. across the three pediatric exercises in year 3 (final three
McNemar’s test was used for the analysis of paired rows in Table 3) was 4.6 (SD 3.2) out of 10.
data. All data analyses were performed using SPSS for Regarding the method used to solve the calculation
Windows 21. When categorizing errors, the research- problems (not including the 69 exercises correspond-
ers sometimes added qualitative comments either to ing to theoretical unit equivalences), in 67.1% (n = 533)
clarify the nature of the error or to justify their choice of cases the student used the rule-of-three method, in
of category. Those comments that clarified the nature 18.0% (n = 143) a conversion factor (i.e. a number for
of errors or which provided extra information about changing given units to desired units), and in 3.1%
them were logged and are considered in the presenta- (n = 25) both these methods. In 93 exercises (11.7%),
tion of results. the student gave an answer directly without using
For years 2 and 3, where more than one exercise was either of these methods. Overall, 90% of the exercises
analyzed for each student, we calculated the overall analyzed were considered complete as the student indi-
mark out of 10 so as to have an overview of the student’s cated a final answer to the problem, although the result
level of knowledge and to facilitate discussion of results. was only correct in 52.7% of cases.

Table 2 Distribution of calculation exercises reviewed and analyzed by course year

Year Source N° exercises reviewed N° (%) exercises analyzed

1 Clinical case (written) of adult patient 95 88 (92.6)

2 Written exam, 10 exercises 690 536 (77.6)
3 Clinical case (written) of adult critical patient 57 50 (87.7)
3 Clinical cases (written) of pediatric patients 192 189 (96.9)
TOTAL 1034 863 (83.5)
Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 5 of 11

Table 3 Calculation exercises attempted and those answered correctly in the sample analyzed
Year Type of calculation required by the exercise Total n Exercises Answered
exercises attempted, correctly, n
reviewed n (%) (%)a

1 Dose concentration and the corresponding infusion rate 95 88 (92.6) 27 (28.4)

2 Unit equivalences (theoretical) 69 69 (100) 8 (11.6)b
2 Basic dose calculation 138 129 (93.4) 117 (84.2)
2 Unit conversion 69 57 (82.6) 41 (59.4)
2 Total infusion time, taking into account the maximum flow rate 69 53 (76.8) 23 (33.3)
2 Dose calculation involving a percentage 69 53 (76.8) 48 (69.6)
2 Dose according to patient’s weight 69 56 (81.1) 44 (63.8)
2 Drug concentration over time (mg/min) 69 43 (62.3) 31 (44.9)
2 Volume of diluent, taking into account the maximum concentration 69 38 (55.1) 2 (2.9)
2 Infusion rate 69 38 (55.1) 10 (14.5)
3 Maintain prescribed dose for different concentration and infusion rate 57 50 (87.7) 17 (29.8)
3 IV dose based on patient’s weight and with unit conversion, plus calculation of infusion rate 64 64 (100) 21 (32.8)
3 Oral dose based on patient’s weight 64 64 (100) 45 (70.3)
3 IV dose based on patient’s weight and with unit conversion, plus calculation of infusion rate 64 61 (95.3) 21 (32.8)
and concentration
Total 1034 863 (83.5) 455 (52.7)
a b
The % of correct answers is calculated based on the total number of exercises reviewed, including those left blank (n = 1034). Students who correctly answered all
the unit equivalence (theory) questions. All exercises were contextualized, with the exception of unit equivalences

Most common errors significantly more incorrect answers (p < .001). Finally, we
Table 4 shows the different aspects of the calculation found that in 16.9% of the exercises analyzed, the student
exercises where errors were observed, distinguishing had clearly not understood the task; this was more com-
between answers that were ultimately correct or incor- monly the case with more difficult exercises or calcula-
rect. For each of these aspects or categories, we exam- tions involving more than one step.
ined statistically the relationship between the presence of Comparison of exercises across the three course years
errors and the proportions of correct and incorrect final showed that the overall number of errors tended to
answers. It can be seen that with the exception of two decrease as students progressed through the degree pro-
categories (i.e., consideration of the diluent solution, and gram, except in relation to performing a mathematical
error carried forward), the presence of errors was asso- calculation (p = .997), for which the proportion of exer-
ciated with a significantly higher proportion of incor- cises containing an error remained fairly stable (between
rect final answers. The areas where errors were most 5 and 9%). However, the proportion of students who
frequently observed concerned an understanding of per- failed to understand the question increased across course
centages and unit equivalences (51.6 and 37.7%, respec- years as the exercises set became more complex (year 1:
tively), as well as calculations involving more advanced 5.7%; year 2: 24%; year 3: 37.7%; p < .001), with a similar
concepts such as maximum concentration and minimum trend being observed for the percentage of students who
dilution (48.7%). We also found, based on those exercises did not follow the correct steps in solving the problem
where it could be analyzed, that in around a third of cases (year 1: 35.2%; year 2: 29.3%; year 3: 52.6%; p = .043).
(32.9%) students did not check whether their answer
made sense and was realistic, with a related problem
being failure to contextualize their result to the patient in Answers according to type of exercise
question (25.3%). Unit equivalences
Importantly, students also had difficulties with more The unit equivalences (theory) exercise in year 2 com-
basic aspects such as calculating the IV infusion rate prises five questions, and only 8 (11.6%) students
(37.7%), the infusion time (29.6%), and the volume of answered them all correctly. The unit equivalence they
solution in which the drug should be dissolved (23.9%). were most familiar with was g – mg (84%), followed
Furthermore, in 51.3% of cases, students did not correctly by ml – cc, ml – microdrops (both 65.2%), mcg (μg) –
extract the key information from the question when try- mg (52.2%), and, finally, the percentage equivalence,
ing to solve the problem, and this was associated with % = mg/ml (18%).
Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 6 of 11

Table 4 Aspects of the exercises analyzed where errors were observed

N (%) Overall Incorrect Correct final answer p-value
final
answer

Uses information given about the stock available (n = 705) No 10 (1.4) 9 (3.2) 1 (0.2) < .001
Partially 15 (2.1) 12 (4.2) 3 (0.7)
Incorrectly 31 (4.4) 29 (10.2) 2 (0.5)
Correctly 649 (92.1) 235 (82.5) 414 (98.6)
Consideration of the diluent solution (n = 206) No 3 (1.5) 3 (3.0) 0 .075*
Partial 4 (1.9) 3 (3.0) 1 (0.9)
Incorrect 10 (4.9) 6 (6.1) 4 (3.7)
Correct 189 (91.7) 87 (87.9) 102 (95.3)
Performs mathematical calculation (n = 794) No 1 (0.1) 1 (0.3) 0 < .001*
Partially 19 (2.4) 17 (4.9) 2 (0.4)
Incorrectly 62 (7.8) 58 (16.7) 4 (0.9)
Correctly 712 (89.7) 271 (78.1) 441 (98.7)
Contextualization to the case (n = 328) No 26 (7.9) 19 (10.4) 7 (4.8) < .001
Partial 27 (8.2) 3 (1.6) 24 (16.4)
Incorrect 83 (25.3) 73 (40.1) 10 (6,8)
Correct 192 (58.5) 87 (47.8) 105 (71.9)
Checks that the result is realistic (n = 343) No 28 (8.1) 19 (10.7) 9 (5.4) < .001
Partially 21 (6.1) 12 (6.8) 9 (5.4)
Incorrectly 112 (32.9) 92 (52.0) 21 (12.6)
Correctly 182 (52.9) 54 (30.5) 128 (76.6)
Extracts the key information from the question (n = 793) No 43 (5.4) 38 (11.0) 5 (1.1) < .001
Partially 348 (43.9) 173 (49.9) 175 (39.2)
Incorrectly 16 (2.0) 16 (4.6) 0
Correctly 386 (48.7) 120 (34.6) 266 (59.6)
Understands the question (n = 863) Partially 61 (7.1) 59 (14.5) 2 (0.4) < .001
Incorrectly 146 (16.9) 145 (35.5) 1 (0.2)
Correctly 656 (76.0) 204 (50.0) 452 (99.3)
Units of measurement in their answer (n = 794) No 27 (3.4) 20 (5.8) 7 (1.6) < .001
Partial 29 (3.7) 20 (5.8) 9 (2.0)
Incorrect 1 (0.1) 1 (0.3) 0
Correct 737 (92.8) 306 (88.2) 431 (96.4)
Correct units of measurement in their answer (n = 772) Partial 37 (4.8) 29 (8.8) 8 (1.8) < .001
Incorrect 83 (10.8) 79 (23.9) 4 (0.9)
Correct 652 (84.5) 223 (67.4) 429 (97.3)
Appropriate volume of diluent (n = 251) Incorrect 60 (23.9) 55 (35.3) 5 (5.3) < .001
Correct 191 (76.1) 101 (64.7) 90 (94.7)
Use of conversion factor (n = 168) Incorrect 8 (4.8) 8 (11.0) 0 .001
Correct 160 (95.2) 65 (89.0) 95 (100)
Use of the ratio-proportion method (n = 554) Incorrect 60 (10.8) 57 (25.8) 3 (0.9) < .001
Correct 494 (89.2) 164 (74.2) 330 (99.1)
Understanding of unit equivalences (n = 289) Incorrect 109 (37.7) 107 (56.9) 2 (2.0) < .001
Correct 180 (62.3) 81 (43.1) 99 (98.0)
Understanding of percentages (n = 122) Incorrect 63 (51.6) 59 (89.4) 4 (7.1) < .001
Correct 59 (48.4) 7 (10.6) 52 (92.9)
Understanding of maximum concentration and minimum dilution (n = 152) Incorrect 74 (48.7) 71 (67.0) 3 (6.5) < .001
Correct 78 (51.3) 35 (33.0) 43 (93.5)
Understanding of continuous and intermittent infusion (n = 436) Incorrect 87 (20.0) 83 (31.7) 4 (2.3) < .001
Correct 349 (80.0) 179 (68.3) 170 (97.7)
Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 7 of 11

Table 4 (continued)
N (%) Overall Incorrect Correct final answer p-value
final
answer

Infusion rate calculation (n = 345) Incorrect 130 (37.7) 122 (56.0) 8 (6.3) < .001
Correct 215 (62.3) 96 (44.0) 119 (93.7)
Infusion time calculation (n = 355) Incorrect 105 (29.6) 100 (45.5) 5 (3.7) < .001
Correct 250 (70.4) 120 (54.5) 130 (96.3)
Knowledge of equipment for drug administration (n = 232) Incorrect 65 (28.0) 59 (36.6) 6 (8.5) < .001
Correct 167 (72.0) 102 (63.4) 65 (91.5)
Follows the correct steps (n = 794) No 260 (32.7) 253 (72.9) 7 (1.6) < .001
Yes 534 (67.3) 94 (27.1) 440 (98.4)
Error carried forward (n = 347) No 78 (22.5) 77 (22.3) 1 (50.0) .400
Yes 269 (77.5) 268 (77.7) 1 (50.0)
The total n for the categories considered in the left-hand column varies because they were not all relevant to every exercise; their relevance depended on the
question being asked. *Fisher’s exact test; for this comparison we grouped the data for the rating categories No/Partial/Incorrect

Exercises referring to an adult patient correctly”, and “calculation is correct, but understands
minutes instead of hours”.
Unit conversion Consistent with the overall results for
the unit equivalences (theory) test, we found that 40.6% One of the exercises in year 3 asked students to maintain
of students in year 2 made a mistake when converting a prescribed dose for a different drug concentration and
units in the clinical exercises. The evaluators commented infusion rate. The most common errors here were a fail-
that two students obtained an incorrect answer because ure to understand the question (48%) and not knowing
they took the abbreviation mcg to mean microdrops (it how to calculate the infusion rate (50%). In their com-
should be noted here that the Spanish word for drop is ments, evaluators noted that 13 students did not how
gota, which led these students to misinterpret the let- to apply the rule-of-three method, and four did not cor-
ter g in mcg). Another comment made was: “they get a rectly extract the information from the question, leading
wrong answer because they don’t know how to convert to wrong answers.
mg to mcg”. Notably, one student failed to double-check
an answer that, in practical terms, was completely unre- Basic dose calculation and administration rate In the
alistic (dose to administer of ­10−6 mg). clinical case exercise in year 1, students had to calculate
both the dose of a prescribed IV drug from the stock
Drug concentration calculations In the dose calculation available and also the corresponding infusion rate. It can
exercise involving a percentage (year 2), 90.6% of stu- be seen in Table 5 that only 36% of students answered
dents obtained a correct answer, much higher than the both parts of this exercise correctly, and in most cases
proportion who, in the theory test, knew that % = mg/ this was due to difficulty calculating the infusion rate
ml. It should be noted that % was defined in this practical (p < .001).
exercise.
The proportion of year 2 students who correctly calcu-
When asked to calculate the drug concentration over lated the dose of an IV drug was higher than in year 1
time (exercise above the knowledge level expected of (correct: 69.3% in year 1 vs. 84.2% in year 2), although
year 2 students), 25.6% of students did not calculate the
infusion time, 20.9% did not understand the question,
and 27.9% made an error that they then carried forward Table 5 Results for the clinical case calculation in year 1
in their calculation. In their comments, the evaluators n (%) Dose calculation
noted that on six occasions the final answer was incor-
Correct Incorrect Total
rect due to rounding or use of a recurring decimal. Other
comments of note included: “treats the diluent as part of Infusion rate Correct 27 (36.0) 4 (5.3) 31 (41.3)
the drug dose”, “doesn’t apply the rule-of-three method Incorrect 25 (33.3) 19 (25.3) 44 (58.7)
Total 52 (69.3) 23 (30.7) 75 (100)
Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 8 of 11

they continued to struggle with the calculation of infu- calculates the ml of aciclovir”) and failed to calculate the
sion rate (correct: 41.3% in year 1 vs. 14.1% in year 2). corresponding volume of diluent.

Regarding the comments made by evaluators about stu- Clinical case exercises We analyzed two clinical pediat-
dents’ dose calculations, it was noted that six students in ric exercises from year 3, both of which required students
year 1 “were confused about the drug stock and thought to make calculations involving more than one step. One
it was a powder vial rather than a liquid ampoule”. of these cases comprises two parts, which were analyzed
Examples of comments made about the year 2 exercises separately.
included: “gets a wrong answer due to rounding in a pre-
vious calculation”, “gives the wrong units”, and “makes a The most frequent errors were not contextualizing their
mistake when multiplying”. With respect to the infusion answer to the case (between 24.6 and 73.3% of answers,
rate calculations, comments related to the year 1 exercise depending on the exercise), not checking that the result
included “mistakes intermittent infusion for continuous was realistic and made sense (between 31.2 and 65.6%),
infusion”, “forgets to add the drug volume to the total and not fully understanding the question (between 7.8
amount of IV solution”, and “chooses the wrong kind of and 26.2%). It should be noted that in one of the exer-
IV solution”, while those for year 2 exercises included cises, 14.1% only partially completed the mathematical
“performs the calculation in ml/h instead of drops/min- calculation and thus could not obtain a final result. In
ute”, “uses the wrong IV infusion set”, and “doesn’t know the other two exercises, some students (6.3 and 14.8%,
how to convert units”. respectively) did not know how to calculate the appro-
priate amount of diluent. Finally, and related to the fact
that these exercises involved multi-step calculations, we
Exercises referring to a pediatric patient found that although the correct steps were followed by
The first three exercises analyzed here come from year between 52.5 and 100% of students (depending on the
2 of the degree program, while the clinical case exer- exercise), the final result was incorrect in between 42.1%
cises correspond to year 3 students. Only the first of the of 63.9% of cases due to an error being carried forward.
3 year 2 exercises (Dose calculation by patient’s weight)
corresponded to the knowledge level expected of year 2
students. Discussion
This article presents a detailed analysis of the errors
Dose calculation by patient’s weight The majority of made by nursing undergraduates when performing writ-
students were able to perform this calculation correctly. ten dose calculation exercises. The results add to existing
Comments made by evaluators regarding incorrect evidence regarding the kinds of problems that nursing
answers included: “divides instead of multiplies so gets students have with calculation exercises [21]. Our anal-
it wrong”, “doesn’t know how to do the calculation”, and ysis suggests that students’ overall level of calculation
“wrong units”. skills is limited, although they are generally able to per-
form basic dose calculations. The proportion of students
Total infusion time, taking into account the maximum who correctly answered the exercises set was slightly
flow rate The large majority of errors here were due to a below that reported in some studies [19, 23, 24], but
lack of understanding of the concepts maximum concen- similar to that observed by Bagnasco et al. [4]. However,
tration and minimum dilution (52.8%), and to confusion our results should be interpreted with caution as a small
between intermittent and continuous infusion (54.7%). number of the year 2 exercises we analyzed included
Overall, 56.6% of students were unable to calculate the questions that went beyond the level of knowledge that
total infusion time. students were expected to have at this point in their stud-
ies; as noted above in Method (sub-section Examination
Volume of diluent, taking into account the maximum con- Papers Reviewed), these more difficult problems were
centration Only two students (5.3%) correctly answered deliberately included as a way of enabling us to track the
this exercise. Most of the errors were related to not progress of individual students in subsequent years of the
understanding the concepts maximum concentration or degree program. If we omit these three questions from
minimum dilution (94.7%) and to not knowing the appro- the analysis, the mean grade obtained by students on this
priate volume of diluent that should be used (73.7%). exam increases from 5.2 (SD 2.2) to 6.3 (SD 2.5) out of 10,
In addition to noting that students didn’t know how to a figure consistent with pass rates reported in the afore-
perform the calculation, evaluators also commented mentioned literature. Given that these year 2 students
that many of them only calculated the drug dose (“only also have two more years of their degree ahead of them,
Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 9 of 11

it would obviously be interesting to follow them up and what they are being asked to do and extract from the
compare their level of achievement on the same kinds of question the key information they need to perform the
dose calculation problems in years 3 and 4, thus provid- calculation correctly [21]. In this context, Grunetti et al.
ing an indication of the level they have reached by the [19] found that while students may find it helpful to use
time they transition to professional practice. a calculator, this can also produce a false sense of secu-
One of the errors we observed, which was also dis- rity, such that they do not then consider whether the
cussed by Bagnasco et al. [4], reflected students’ dif- result makes sense or not. This kind of error is much
ficulty with converting units. In Spain, this concept is more common among students who do not have a good
taught during secondary education (with the exception of grasp of the principles of mathematical calculation or
% = mg/ml and drops – ml), and hence students should who struggle with logical reasoning [27]. An example
be able to perform this operation by the time they enter from our analysis was a student who did not question a
university. More specifically, we found that students had final result giving a drug dose of 1­ 0− 6 mg, even though
greater difficulty moving up the scale of units (e.g., from it should be obvious that it is impossible to administer
mcg to mg) rather than down, and also that some students such a small amount to a patient. In our view, clinical
correctly converted units in the clinical case exercise but simulation with manikins is a highly useful tool for help-
not in the unit equivalences theory test, and vice-versa. ing students develop their skills in this respect [27, 28],
Given their importance in clinical practice, greater atten- insofar as it allows them to see the practical result of their
tion needs to be paid to these concepts during students’ calculations (i.e., the drug volume to administer), in addi-
training. tion to providing them with an opportunity to improve
Our analysis also showed that students were more their critical thinking [29] and to learn from mistakes and
likely to produce a correct answer when they applied a their peers [30]. It should also be noted that simulation is
structured approach to the problem (e.g., extract all the not a stress-free experience for students, as they will be
key information from the question, use the correct units, observed and be set a time limit for performing the task,
and follow the correct calculation steps). This structured and in this respect it more closely resembles the realities
approach is taught at earlier stages of education in our of clinical practice [31]. As an alternative or complement
country, although it may not be adequately assimilated by to simulation, one might also use more active learning
all students. If this is the case, then it could have a nega- strategies or those in which students can see the material
tive impact on their ability to perform medication calcu- they need or visualize what is being explained to them,
lations, which tend to be more complex in content than rather than it being presented in abstract or purely theo-
the purely arithmetic problems they will have been set retical terms [1, 26].
during secondary education [21, 25]. Another important difficulty that students had, regard-
Obviously, students would most likely find calculation less of the course year they were in, concerned calcula-
exercises easier if they involved a single task expressed in tion of the IV infusion rate. In our view, this suggests a
clear and concise terms. However, this would not reflect gap between theory and practice in this respect, because
clinical reality, because in practice a dose calculation is although students are taught in class how to calculate
made in the context of a specific patient and other vari- the infusion rate, they are unlikely to see clinical nurses
ables that may affect the final result must also be taken calculate the drip rate in drops/minute as this is usually
into account. Setting students contextualized case exer- estimated by the nurse when setting up a manual IV set
cises therefore helps to reduce the theory-practice gap [32]. By contrast, students do gain practical experience of
[26]. Accordingly, the exercises analyzed in this study calculating the rate in ml/h, because these are the units
involved clinical scenarios of varying complexity, and used with infusion pumps. In accordance with Hedlund
it was noticeable that the easier questions (those with et al. [3], we also found that students had difficulties in
just one or two calculation steps) were more likely to be calculations involving the total administration time or
answered correctly than were the more complex multi- the volume of diluent, both of which are more theoreti-
step problems. This is reflected in the proportion of exer- cal pharmacological concepts. A task for future research
cises where the student had clearly not understood the would be to examine in more detail the possible relation-
question (16.9%), which tended to be the more difficult ship between students’ exposure to these kinds of calcu-
problems involving more than one calculation [25]. In lations while on clinical placement and their performance
those exercises (n = 328) where it was possible to ana- in written examinations.
lyze whether the student had contextualized their result The present study has several limitations that derive
and checked whether it was realistic and made sense, we from the retrospective design and the fact that the analy-
found that 45.5% failed to do so. In order to solve prob- sis is based solely on written dose calculation exercises.
lems of this kind, students must understand precisely One is that we do not know why some exercises were left
Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 10 of 11

blank, that is to say, whether it was because the student answer was realistic and made sense in a clinical context
did not know how to solve the problem or simply ran out is problematic from the point of view of safe medication
of time during the exam. Neither is it clear whether the management. The use of high-fidelity simulation scenar-
number of correct answers would have been greater if ios during their training could play an important role in
students had been allowed more time or did not feel the helping them improve their skills in this respect.
pressure of an exam situation. On a related issue, we have
no way of knowing whether those students who gave a
correct answer were confident about their calculations or Relevance to clinical practice
got there more by luck than judgment. It would therefore In order to ensure that nursing students are proficient in
be useful in future studies to complement an analysis of medication calculation by the time they graduate, nurse
this kind with qualitative feedback from students them- educators need to identify the specific aspects and steps
selves regarding the difficulties they experienced and in the process that students find most difficult, thus ena-
their level of confidence in their answers. Our approach bling instruction to be targeted where it is most needed.
here also provides no insight into students’ thought pro- The present analysis of students’ answers to a series of
cess or reasoning, which would be necessary in order dose calculation exercises of varying levels of complex-
to understand more about why precisely they made the ity shows that their errors cannot be attributed solely to
errors they did. This would also be an interesting topic poor calculation skills, insofar as they involved different
for future research. As noted earlier, three of the exer- aspects and stages of the problem-solving process. Nota-
cises set during year 2 imply a knowledge level above that bly, students often struggled to understand key concepts
expected of students at this stage of their training, the associated with dose calculation and failed to follow the
rationale being that this allows us to track the progress correct steps when performing the exercises set. Nurse
of individual students over subsequent years of their education programs must, in addition to developing stu-
studies. We acknowledge, however, that in the context of dents’ mathematical competence, ensure they acquire
the present analysis the inclusion of these exercises may an adequate understanding of the key concepts (both
bias the results obtained for year 2 students, which must numerical and clinical) underpinning medication cal-
therefore be interpreted with caution. A final limitation culation, as well as an appreciation of the importance of
to consider is that we have no comparative data among checking that their result is realistic and makes sense in
the years of nursing degree regarding the dose calculation relation to each individual patient.
skills. Moreover, students spend year 4 almost entirely on
placement, making it difficult to schedule a classroom- Supplementary Information
based test their ability in this respect. In order to build on The online version contains supplementary material available at https://​doi.​
the present results, it would be useful to introduce a final org/​10.​1186/​s12912-​022-​01085-9.
written examination (such as that used with year 2 stu-
Additional file 1.
dents) at the end of every year so as to explore the evolu-
tion of the knowledge and level that our students reach
by the time they graduate. Acknowledgements
We would like to thank Karen Liseth Rojas Manzano for her help in the final
Notwithstanding these limitations, our study also has editing of the manuscript.
two important strengths: One is the large number and
variety of dose calculation exercises analyzed, while the Authors’ contributions
Wennberg-Capellades, L: Methodology, investigation, formal analysis, data
other is the detailed analysis of the aspects that students curation, writing original draft, writing review and editing. Fuster-Linares, P:
find most difficult. Conceptualization, methodology, investigation, writing review and editing.
Rodriguez-Higueras, E: Methodology, investigation, writing review and editing.
Gallart Fernández-Puebla, A: Methodology, investigation, writing review and
Conclusions editing. Llaurado-Serra, M: Methodology, investigation, formal analysis, data
curation, writing original draft, writing review and editing, supervision. The
Nursing students have adequate skills when it comes to authors read and approved the final manuscript.
basic dose calculations, but struggle with more complex
problems, although they tend to improve as they pro- Funding
This study was supported through funding from AGAUR (the Catalan Agency
gress through their studies. The most common errors for the Management of University and Research Grants (2017SGR141) and
we observed were related to not understanding or not the Business Chair DECIDE (UIC-Boehringer Ingelheim). Neither of the sources
extracting the key information from the question, not fol- mentioned have been involved in the development of the study.
lowing the correct steps in their calculations, and a lack Availability of data and materials
of basic knowledge such as how to convert units. The The regulations of our university that cover the use of data from students do
fact that some students did not consider whether their not allow us to share these datasets publicly. However, data in the form of
Wennberg‑Capellades et al. BMC Nursing (2022) 21:309 Page 11 of 11

aggregated results are available from the corresponding author upon reason‑ programmes. 2018. Available from: https://​www.​nmc.​org.​uk/​globa​lasse​ts/​
able request. sited​ocume​nts/​educa​tion-​stand​ards/​progr​amme-​stand​ards-​nursi​ng.​pdf.
15. National Agency for quality assessment and accreditation (ANECA). White
paper. Bachelor’s degree in nursing. National Agency for Quality Assessment
Declarations and Accreditation 2004:1–336. Available from: http://​www.​aneca.​es/​var/​
media/​150360/​libro​blanco_​jun05_​enfer​meria.​pdf.
Ethical approval and consent to participate 16. Fleming S, Brady AM, Malone AM. An evaluation of the drug calculation
This study was approved by the research ethics committee of the Universitat skills of registered nurses. Nurse Educ Pract. 2014;14(1):55–61. https://​doi.​
Internacional de Catalunya (UIC Barcelona) (ref. INF-2018-05). The need for org/​10.​1016/j.​nepr.​2013.​06.​002.
informed consent was waived by the ethics committee due to the retrospec‑ 17. Luokkamäki S, Härkänen M, Saano S, Vehviläinen-Julkunen K. Registered
tive nature of the study. nurses’ medication administration skills: a systematic review. Scand J Caring
Sci. 2021;35(1):37–54. https://​doi.​org/​10.​1111/​scs.​12835.
Consent for publication 18. McMullan M, Jones R, Lea S. Patient safety: numerical skills and drug
Not applicable. calculation abilities of nursing students and registered nurses. J Adv Nurs.
2010;66(4):891–9. https://​doi.​org/​10.​1111/j.​1365-​2648.​2010.​05258.x.
Competing interests 19. Grugnetti AM, Arrigoni C, Bagnasco A, Grugnetti G, Menoni S, Casey M,
The authors declare no conflict of interest. et al. Evaluating the effectiveness of calculator use in drug dosage calcula‑
tion among Italian nursing students: a comparative study. Int J Clin Skills.
Received: 9 May 2022 Accepted: 27 October 2022 2017;11(2):57–64.
20. Khasawneh E, Gosling C, Williams B. What impact does maths anxiety have
on university students? BMC Psychol. 2021;9(1):37. https://​doi.​org/​10.​1186/​
s40359-​021-​00537-2.
21. Weeks KW, Lyne P, Torrance C. Written drug dosage errors made by students:
References the threat to clinical effectiveness and the need for a new approach. Clin Eff
1. Wright K. An investigation to find strategies to improve student nurses’ Nurs. 2000;4(1):20–9. https://​doi.​org/​10.​1054/​cein.​2000.​0101.
maths skills. Br J Nurs. 2004;13(21):1280–7. https://​doi.​org/​10.​12968/​bjon.​ 22. STROBE strengthening the reporting of observational studies in epidemiol‑
2004.​13.​21.​17114. ogy [internet]. STROBE Checklist 2022 [Cited August 1­ 6th 2022]. Available
2. Ross LM. Medication errors in a paediatric teaching hospital in the UK: five from: https://​www.​strobe-​state​ment.​org/​check​lists/.
years operational experience. Arch Dis Child. 2000;83(6):492–7. https://​doi.​ 23. Dilles T, Vander Stichele RR, Van Bortel L, Elseviers MM. Nursing students’
org/​10.​1136/​adc.​83.6.​492. pharmacological knowledge and calculation skills. Nurse Educ Today.
3. Hedlund N, Beer I, Hoppe-Tichy T, Trbovich P. Systematic evidence review of 2011;31(5):499–505. https://​doi.​org/​10.​1016/j.​nedt.​2010.​08.​009.
rates and burden of harm of intravenous admixture drug preparation errors 24. Özyazıcıoğlu N, Aydın Aİ, Sürenler S, Çinar HG, Yılmaz D, Arkan B, et al. Evalu‑
in healthcare settings. BMJ Open. 2017;7(12):e015912. https://​doi.​org/​10.​ ation of students’ knowledge about paediatric dosage calculations. Nurse
1136/​bmjop​en-​2017-​015912. Educ Pract. 2018;28:34–9. https://​doi.​org/​10.​1016/j.​nepr.​2017.​09.​013.
4. Bagnasco A, Galaverna L, Aleo G, Grugnetti AM, Rosa F, Sasso L. Mathemati‑ 25. McMullan M, Jones R, Lea S. Math anxiety, self-efficacy, and ability in British
cal calculation skills required for drug administration in undergraduate nurs‑ undergraduate nursing students. Res Nurs Health. 2012;35(2):178–86.
ing students to ensure patient safety: a descriptive study: drug calculation https://​doi.​org/​10.​1002/​nur.​21460.
skills in nursing students. Nurse Educ Pract. 2016;16(1):33–9. https://​doi.​org/​ 26. Weeks KW, Lyne P, Mosely L, Torrance C. The strive for clinical effective‑
10.​1016/j.​nepr.​2015.​06.​006. ness in medication dosage calculation problem-solving skills: the role of
5. Elonen I, Salminen L, Brasaitė-Abromė I, Fuster P, Kukkonen P, Leino-Kilpi H, constructivist learning theory in the design of a computer-based “authentic
et al. Medication calculation skills of graduating nursing students within world” learning environment. Clin Eff Nurs. 2001;5(1):18–25. https://​doi.​org/​
European context. J Clin Nurs. 2022;31(5-6):548–58. https://​doi.​org/​10.​1111/​ 10.​1054/​cein.​2001.​0180.
jocn.​15908. 27. Jarvill M, Jenkins S, Akman O, Astroth KS, Pohl C, Jacobs PJ. Effect of simula‑
6. Caboral-Stevens M, Ignacio RV, Newberry G. Undergraduate nursing tion on nursing students’ medication administration competence. Clin
students’ pharmacology knowledge and risk of error estimate. Nurse Educ Simul Nurs. 2018;14:3–7. https://​doi.​org/​10.​1016/j.​ecns.​2017.​08.​001.
Today. 2020;93:104540. https://​doi.​org/​10.​1016/j.​nedt.​2020.​104540. 28. Pettigrew J, Stunden A, McGlynn S. Contextualising numeracy skill develop‑
7. Williams B, Davis S. Maths anxiety and medication dosage calculation errors: ment and assessment in a first year undergraduate nursing subject: a mixed
a scoping review. Nurse Educ Pract. 2016;20:139–46. https://​doi.​org/​10.​ methods research study. Nurse Educ Today. 2020;92:104426. https://​doi.​org/​
1016/j.​nepr.​2016.​08.​005. 10.​1016/j.​nedt.​2020.​104426.
8. Johnson J, Kareem A, White D, Ngwakongnwi EM, Mohammadpour M, 29. Shin H, Ma H, Park J, Ji ES, Kim DH. The effect of simulation courseware on
Rizkika N, et al. Nursing students’ perspectives on learning math for medica‑ critical thinking in undergraduate nursing students: multi-site pre-post
tion calculations in a Canadian nursing program in Qatar. Nurse Educ Pract. study. Nurse Educ Today. 2015;35(4):537–42. https://​doi.​org/​10.​1016/j.​nedt.​
2020;49:102885. https://​doi.​org/​10.​1016/j.​nepr.​2020.​102885. 2014.​12.​004.
9. Gill M, Andersen E, Hilsmann N. Best practices for teaching pharmacology to 30. Palominos E, Levett-Jones T, Power T, Martinez-Maldonado R. Healthcare
undergraduate nursing students: a systematic review of the literature. Nurse students’ perceptions and experiences of making errors in simulation: an
Educ Today. 2019;74:15–24. https://​doi.​org/​10.​1016/j.​nedt.​2018.​11.​017. integrative review. Nurse Educ Today. 2019;77:32–9. https://​doi.​org/​10.​
10. Grugnetti AM, Bagnasco A, Rosa F, Sasso L. Effectiveness of a clinical skills 1016/j.​nedt.​2019.​02.​013.
workshop for drug-dosage calculation in a nursing program. Nurse Educ 31. Shearer JN. Anxiety, nursing students, and simulation: state of the science.
Today. 2014;34(4):619–24. https://​doi.​org/​10.​1016/j.​nedt.​2013.​05.​021. J Nurs Educ. 2016;55(10):551–4. https://​doi.​org/​10.​3928/​01484​834-​20160​
11. Karabağ Aydin A, Dinç L. Effects of web-based instruction on nursing 914-​02.
studentsʼ arithmetical and drug dosage calculation skills. Comput Inform 32. Rooker JC, Gorard DA. Errors of intravenous fluid infusion rates in medical
Nurs. 2017;35(5):262–9. https://​doi.​org/​10.​1097/​CIN.​00000​00000​000317. inpatients. Clin Med. 2007;7(5):482–5. https://​doi.​org/​10.​7861/​clinm​edici​
12. Renmarker E, Carlson E. Evaluation of Swedish nursing students’ experience ne.7-​5-​482.
of a web-based platform for drug calculation. Nurse Educ Pract. 2019;38:89–
95. https://​doi.​org/​10.​1016/j.​nepr.​2019.​06.​010.
13. Stolic S. Educational strategies aimed at improving student nurse’s medica‑ Publisher’s Note
tion calculation skills: a review of the research literature. Nurse Educ Pract. Springer Nature remains neutral with regard to jurisdictional claims in pub‑
2014;14(5):491–503. https://​doi.​org/​10.​1016/j.​nepr.​2014.​05.​010. lished maps and institutional affiliations.
14. Nursing and Midwifery Council. Realising professionalism: Standards
for education and training Part 3: Standards for pre-registration nursing