Medication errors in South Korea have steadily increased in the past 4 years, during which 3,798 cases occurred, accounting for 31.8% of patient safety accidents [1]. Medication errors take place in the prescription, distribution, application, monitoring, system, and control processes of administering medication. Since medication errors occur at the individual, system, and management levels in each process, a systematic and complete prevention system should be implemented and errors in individual factors should be identified and educated [2,3]. Errors with the potential to cause harm are eight times more likely to occur in the neonatal intensive care unit (NICU) than in adult settings [1]. Medication errors have a high risk of harming newborns due to their large body surface relative to their low body weight and immature body functions that affect drug absorption, transfer, metabolism, and excretion [4,5]. Despite the utilization of advanced medication injection machines, computerization of prescription systems, and medication safety guidelines to prevent medication errors in the NICU, medication errors in the NICU continue to occur as nurses directly prepare small doses of drugs administered to newborns [1,3,5]. In prescriptions of high-alert medications in the NICU, 64% of medication errors involved the incorrect name or dose of a medication prescribed verbally by doctors communicating to nurses [3]. While teaching students to care for newborns in the NICU is a priority in pediatric nursing curricula, avoiding medication errors has been identified as problematic for learners, as communication problems may contribute to medication errors and nursing students find it difficult to recognize and report such conditions.

Effective communication among medical staff is emerging as the most important competency to prevent medication errors [2]. The US Agency for Healthcare Research and Quality (AHRQ) reported that communication among medical staff is essential for patient safety, and that there is a need for communication competency-based education for patient safety accompanied by thorough monitoring for medication safety management [6]. According to priming patient safety theory, safety nursing hand-off communication elicited a change in nursing safety-oriented behavior [5]. Nurses subsequently prioritize and are motivated to perform tasks and risk assessments related to achieving patient safety. These efforts continue until nurses mitigate identified risks and errors during the patient care encounter. Hand-off communication involves more than information transfer, and the consequences of hand-off communication for multi-functional, situated routines extend beyond patient safety [5]. SBAR (situation, background, assessment, recommendation) is a standardized method for efficient communication among medical staff aiming to deliver fast and correct information about patients' conditions in emergencies, and it has been shown to reduce harmful accidents [7]. Although studies on patient safety competency have confirmed that SBAR training improves communication skills, relatively few studies have applied SBAR to strengthen nurses' hand-off communication ability during the routine practice of medication [8,9].

The use of simulations is supported by the Institute of Medicine as a strategy to improve patient safety and support the transfer of learning to the clinical setting [2]. Simulations provide an opportunity to demonstrate clinical judgment and make decisions in a safe environment while witnessing the consequences and evaluating the effectiveness of actions [6,7]. Simulation-based emergency airway management education for NICU nurses improved their problem-solving ability and clinical performance confidence [10]. Bonds [7] utilized SBAR in a simulation, resulting in nurses gaining practice with communicating more effectively to their individual disciplines with the patient safety competency. Although simulations have been suggested as a highly useful strategy to increase communication skills and safety competency [4,5], insufficient studies have investigated simulations dealing with NICU medication safety for nursing students.

An integrated review study concluded that communication clarity and patient hand-off confidence prevent serious medication errors and increase patient safety competency, and simulations included using SBAR to report medication errors to nurses and medical staff, as well as knowing safe medication administration practices in the NICU [6-9]. Therefore, this study aimed to develop a NICU medication safety simulation (NMSS) focusing on communication and to evaluate its effects on nursing students' communication clarity, patient hand-off confidence, and patient safety competency.

The general characteristics did not show significant differences between the experimental group and the control group. For the pretest variables, there were no significant differences in communication clarity and patient safety competency between the two groups (Table 2). According to the Kolmogorov-Smirnov analysis results, all variables had a normal distribution (p>.05).

The mean differences in scores for communication clarity, hand-off confidence, and patient safety competency between the groups are presented in Table 3. The pre-post test scores for the variables were analyzed using the independent t test. The experimental group had significantly higher scores for communication clarity and patient safety competency than the control group (Figure 2). Communication clarity demonstrated a significant increase, with scores of 4.14±0.09 in the experimental group and 4.00±0.08 in the control group at the posttest (t=2.23, p=.015) (Figure 2). For patient safety competency, a statistically significant difference was found, with scores of 4.13±0.80 in the experimental group and 3.78±0.08 in the control groups (t=4.06, p<.001) (Figure 2). However, the score for the subdomain of attitudes did not show a significant difference in this regard (Table 3).

For the patient hand-off, between-group scores were compared using ANCOVA. Using the pretest values as covariates, patient hand-off confidence scores significantly increased in the posttest, with 3.16±0.08 points in the experimental group and 3.03±0.08 points in the control group (F=5.18, p=.027) (Table 3, Figure 2).

This study was conducted to develop and verify the effectiveness of simulation education for enhancing communication clarity, patient hand-off confidence, and safety competency in situations related to medication errors in the NICU for nursing students.

First, the NMSS improved nursing students' communication clarity. This is similar to the result found in a study [18] that provided team-based simulation practice applying SBAR for nursing students, resulting in improved communication clarity. Another study also found that nursing students' communication skills and self-efficacy in communication were improved by a program in which students practiced frequent communication situations in clinical settings [19]. SBAR, a structured communication tool that includes the patients' current problems, medical history, current symptoms, and vital signs and nurses' recommendations, facilitated effective communication between nurses and physicians in the NICU. Because ineffective communication among health care team members contributes to patient harm and adverse medication errors, communication clarity becomes instrumental in preventing negative patient outcomes. Role play based on a real case scenario in simulations provides learners with targeted communication practice and feedback to acquire and thereby improve communication clarity with each other in various situations. Hence, we believe that the NMSS could allow students to train themselves on how to handle NICU medication errors according to real nurses' roles through scenario-based learning, as well as an opportunity to learn SBAR reporting. Continued education and training on communication for nursing students will help them strengthen their patient safety competency and improve the quality of nursing care when they become new nurses.

Second, this simulation improved nursing students' hand-off confidence. This is similar to the finding of a previous study that nursing students who participated in hand-off simulation practice had higher hand-off confidence than those who only participated in the general practice [20]. However, this result was different from Park and Im's study [21], in which a hand-off simulation practice was conducted and it was found that the hand-off confidence improved, but the hand-off performance capability did not. The above considerations suggest that effective debriefing is important in simulation practice. In this study, two factors appear to have contributed to improving hand-off confidence: 1) repeatedly providing training on hand-off methods using SBAR in the event of a medication error through lectures, videos, clinical case studies, and simulation practice; and 2) documenting the hand-off process in person immediately after scenario performance and conducting a debriefing to check their shortcomings by observing recorded videos. In the debriefing process, students had time to reflect on and reorganize their simulation practice experience. Since patient hand-offs among nurses are an important communication process for improving nursing quality and patient safety, there is a need for structured and standardized communication techniques such as SBAR along with the implementation of checklists to reduce safety errors [22]. To enhance nursing students' hand-off confidence, repeatedly educating them through simulations of specific situations is necessary.

Third, the implementation of NMSS was effective in increasing patient safety competency. This is similar to Park's study [23], in which a risk prediction simulation for nursing students improved self-efficacy regarding patient safety. This is also similar to a study finding that team-based simulation exercises on patient safety for nursing students and interns in internal medicine led to improved confidence in patient safety [24]. Nurses' high workload in the NICU due to the use of high-alert medications and the considerable variety of medical equipment, given the characteristics of newborns, could increase their vulnerability to patient safety incidents such as medication errors [21]. The NMSS improved nursing students' understanding of medication errors based on priming patient safety theory. It also provided opportunities to self-determine the causes and solutions for medication errors that frequently occur during routine work in the NICU, considering the use of TPN, fat emulsion, fentanyl, and anti-infective agents, as well as EMR prescription errors. In addition, SBAR communication is a technique designed to facilitate effective and direct communication among medical staff in busy situations, and it features a short, structured, and predictable format for the effective delivery of important information in the NICU.

In this study, significant differences between the two groups were found in patient safety knowledge and skills, but not in attitudes. These findings indicate that the NMSS may be an effective method for educating nurses about patient safety knowledge and skills. These findings are consistent with the existing literature identifying that simulations can enhance safety education programs in the NICU [25]. Although patient safety attitudes did not show a statistically significant difference between groups, the pre-posttest difference in attitudes showed a slightly greater decrease in the experimental group than in the control group. Attitudes toward patient safety included recognition of the organizational culture related to patient safety, the use of standardized systems such as information technology and electronic data processing systems for patient safety, and negative perceptions of errors; thus, it might not be reasonable to expect that a single educational session would improve students' attitudes [7,21,23]. According to the students' reports, students' negative perceptions and attitudes toward medication errors became stronger, and communication in a structured process became stressful and more burdensome after exposure.

In addition, NICU nurses may not consider that they contribute to patient safety through their constant routine actions to manage risk [6,25]. For example, the goal of working with a clean syringe pump motivated actions such as checking the machine's operation; however, those actions also decreased the risk of infection, supporting the goal of patient safety. The way to improve students' patient safety attitudes is to avoid creating a task mindset, and instead foster an outcome focus that emphasizes the connections between nursing interventions and patient safety attitudes. The NMSS training program, with its focus on medication tasks using high-fidelity simulation scenarios, followed by debriefing, may be an evidence-based approach for helping nursing students improve their patient safety attitudes.

This study is meaningful in that it developed a simulation program consisting of theoretical education, case-based practice training, and simulation practice realistically reflecting medication errors in the NICU. Scenarios should incorporate key messages into patient safety processes rather than simply creating a single medication error to address an individual communication ability. The simulation had beneficial effects not only on medication safety confidence and competence, but also on SBAR reporting and medication safety actions in the process of routine tasks. It is also significant that the simulation improved the safety competencies of nursing students, including communication clarity and hand-off confidence, which are applicable to the clinical field.

The results of this study have limited generalizability because they were obtained from students at a single institution instead of using a randomized controlled design. Although we attempted to minimize confounding factors separately through group assignment, convenience-based allocation may not have been excluded completely. Another limitation is the failure to account for potential confounding variables, including the type of clinical experiences, academic performance, and school satisfaction. This program explored only the short- term impact on nursing students' patient safety competency. Therefore, we propose a study to identify the long-term effects of the patient safety program on nursing students' patient safety-related competency when they work in clinical settings as new nurses. In addition, we suggest conducting further research to verify the effects of this program by developing scenarios for NICU patient safety incidents other than medication errors.

Newborns admitted to the NICU are vulnerable to medication error incidents, underscoring the need for communication clarity practice for nursing students in the NICU. Nursing students already have the goal of patient safety as a result of their pediatric nursing education and training; however, unexpected routine demands in the NICU for nursing time and attention can cause medication errors. The pediatric nursing curriculum should include medication safety theory and skills beyond the "Five Rights" construct. Furthermore, nursing educators must guard against viewing the goal of patient safety as a singular or one-time intervention.

This study implemented a simulation program using SBAR that incorporated communication clarity and patient hand-off confidence and patient safety competency. The findings provide evidence supporting the effect of communication simulations on expanding nursing students' understanding of medication safety in the NICU. Communication simulation will help provide education that involves various scenarios and repeated feedback, so that nursing students will be adequately trained in medication safety. Effective communication with SBAR documentation could serve as a surrogate marker during critical patient events in the NICU.