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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 134-139

Case-based learning versus flipped classroom teaching model for the improvement of pediatric drug dose calculation skills of Pharm. D Students

1 Department of Pharmacy Practice, College of Pharmacy, Sri Ramakrishna Institute of Paramedical Sciences, Coimbatore, Tamil Nadu, India
2 Department of Pharm. D Intern, College of Pharmacy, Sri Ramakrishna Institute of Paramedical Sciences, Coimbatore, Tamil Nadu, India

Date of Submission12-May-2020
Date of Decision27-Jul-2020
Date of Acceptance18-Sep-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
A S Manjula Devi
Department of Pharmacy Practice, College of Pharmacy, Sri Ramakrishna Institute of Paramedical Sciences, Coimbatore - 641 044, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_33_20

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Background: Pharm. D students are expected to be proficient in calculating drug dosages. Drug dosage calculations in pediatrics require much attention as infants and children respond differently to adult doses. Students must be capable of calculating accurate doses and also identify any dosing errors in the prescription.
Aim: To determine the effectiveness of two teaching–learning strategies such as case-based learning (CBL) and flipped classroom teaching model (FCTM) for the improvement of pediatric drug dose calculation skills of Pharm. D students.
Methodology: CBL materials and workbook for FCTM were designed. Students were divided into two equal groups and were asked to take a pretest. The students were exposed to the two teaching–learning strategies and were then asked to take a posttest.
Results: The majority of students showed positive improvement in the posttest scores. It was observed that both strategies were effective. Statistical analysis demonstrated that CBL showed a more significant difference in the pre- and posttest scores.
Conclusion: Significant improvement in students' performance with improvement in clinical decision-making and professional thinking skills indicates the effectiveness of these two strategies for teaching drug dose calculations. It was found that CBL had a more significant impact than the FCTM in improving the drug dose calculation skills of Pharm. D students.

Keywords: Case-based learning, drug dose calculation skills, flipped classroom teaching model, pediatrics, pharmacy education

How to cite this article:
Manjula Devi A S, Babu KA, Sri J K, Priya K K, Mathew NA. Case-based learning versus flipped classroom teaching model for the improvement of pediatric drug dose calculation skills of Pharm. D Students. J Curr Res Sci Med 2020;6:134-9

How to cite this URL:
Manjula Devi A S, Babu KA, Sri J K, Priya K K, Mathew NA. Case-based learning versus flipped classroom teaching model for the improvement of pediatric drug dose calculation skills of Pharm. D Students. J Curr Res Sci Med [serial online] 2020 [cited 2023 May 30];6:134-9. Available from: https://www.jcrsmed.org/text.asp?2020/6/2/134/304203

  Introduction Top

Drug dose calculation errors are common. Such errors have long since been shown to be a cause of illness and mortality. These errors could sometimes be more life-threatening to infants and small children. To prevent such errors, specific measures have been recommended, and they include double-checking calculations and patient-unit doses prepared in the hospital pharmacy. Medical pharmacists have the duty to identify and prevent such erroneous dose orders written by pediatric physicians and trainees, and also identify errors in preparation and administration of drugs by the nurses, which would otherwise result in severe illness or death. Such errors may be influenced by many factors such as inadequate medical knowledge, excessive workload, and fatigue including simple calculation errors.[1]

As pharmaceutical care is a patient-centered, outcome-based pharmacy practice, the pharmacist conjoins with the patient and other health-care professionals in designing, executing, and keeping track of a therapeutic plan that will produce specific therapeutic outcomes for the patient.[2] It helps promote health, prevent disease, assess, monitor, initiate and modify medication use, and assure that drug therapy routines are safe and effective. Various skills required for pharmaceutical care services are cognitive skills, management skills, communication skills, listening skills, professional behaviors, and observational and perception skills. The importance of pharmaceutical calculation skills is to ensure the accuracy of drug treatment and patient safety by providing the correct dose and to avoid underdosing and overdosing.

Calculation skills are fundamental, and various approaches have been tried to teach students how to calculate dosages accurately. The main types of calculation required in drug dosing are the conversion of units, using formulas for calculation of dose, quantity or strength, infusion rate, dilutions, the volume of drug to be administered, etc.[3] In children, the pharmacokinetic processes of absorption, distribution, metabolism, and excretion change due to growth and development. On this regard, drug dosing is calculated based on body weight, body surface, age, and other factors appropriately for children. Hence, much awareness should be given to the calculation of dose for the medication in children.[4] Studies have reported the occurrence of medication errors in children due to errors in dosing which require appropriate interventions.[5],[6],[7] Errors in calculating drug doses in infants and small children can cause significant morbidity and mortality, especially with drugs exhibiting narrow therapeutic window.[1] Lack of appropriate education among health professionals, in drug dose calculations, increases the risk of adverse drug events. Moreover, the current Pharm. D curriculum in India lacks proficiency in drug dose calculation skills. Lack of formal teaching on dose calculation may make students liable to errors during practice, resulting in severe consequences on patient safety.[8]

Pharmacy students must develop sufficient skills in pharmaceutical calculations. The students value the technology's flexibility, convenience, and usability in learning, which helps improve confidence and competence in performing pharmaceutical calculations.[9] On review of literature, there seems to be a lack of research in this area of drug dosage calculation proficiency that could lead to dangerous medication errors and a threat to patient safety.[10] There are various teaching methods which can be used to teach drug dose calculations. Learning styles depend on several factors such as age, gender, and previous experience, and therefore, various studies have explored the effectiveness of different teaching–learning strategies to improve students' drug dose calculation skills.[9] The majority of the research has been conducted in the nursing profession, but the findings can be equally applied to the pharmacy profession as well. Students will appreciate the flexibility of well-prepared materials in addition to face-to-face tutorials and lectures. Improvement in calculations skills may be seen as a result of blending different approaches to teach drug dose calculation.[9]

Drug dose calculation teaching is significant throughout the Pharm. D curriculum and during practice. The various teaching–learning approaches for inculcating the skill sets required for providing effective pharmaceutical care services include traditional lecture, drug calculation workbooks, practical sessions in skills laboratory, constructivist learning environment, simulation, Polýa's four phases of problem-solving framework, case-based approach, problem-based learning, and flipped classroom teaching. Multiple teaching strategies have been implemented, showing a moderate amount of success since no single method has been able to produce acceptable success rates in all of the participants.[11] Here, we compare two strategies, case-based learning (CBL) approach and flipped classroom teaching model (FCTM), for their effectiveness in improving drug dose calculation skills in Pharm. D students. Most students only memorize the concepts and their calculation, which may adversely affect the patient safety at clinical settings. To reduce the gaps between theory and practice, a case-based tutorial can be used as a strategy, which exposes the students to the concepts with cases, and it is mostly student oriented.[12] CBL is an established approach used across various disciplines where students apply their knowledge to real-world scenarios, promoting higher levels of cognition.[13] In this, the students can use cases as guidelines for future decision-making.

The flipped classroom (referred to as reverse, inverse, or backward classroom) is a pedagogical approach, in which the students study the topic independently outside of the classroom and then spend the class time solving problems, applying the concepts to case studies, or doing practical application activities. The fliipped classroom is a new method. It is a unique combination of learning involving interactive, problem-based activities for improving dose calculation skills in students.[14] Flipped classes enable instructors to spend time with students and help them toward improving their critical thinking.[15]

In the digital age, students have access to more content than ever before, making learning and the gathering of information easier to enhance learning outcomes. Providing students with the original content before class enables students to learn the concept at their own pace, depending on how much content they can grasp. When designed expertly, this preclass learning provides the essential foundation for class application, which is then reinforced through after-class practice.[16] Although these two methods (CBL and FCTM) prove to be effective, it would be good to know the strengths of each teaching model to identify the best among them, for inculcating calculation skills in Pharm. D students.

  Methodology Top

Study site

Pediatric department of a 1000-bedded private corporate hospital.

Study duration

Six months.

Study design

A quasi-experimental, quantitative design.

Sample size


Inclusion criteria

Students accepted into the Pharm. D program as per the norms of Pharmacy Council of India (PCI) and students who are willing to participate in the study were included in the study. Students in this group must be in the 5th or 6th year (regular and postbaccalaureate) of the Pharm. D course to be eligible.

Exclusion criteria

Students who are not willing to participate in the study and students who are repeating the course were excluded from the study.


The study was initiated after obtaining approval from the Scientific and the Hospital Ethical Committee. During hospital ward rounds, various types of cases requiring drug dose calculations were collected in the specially designed structured pro forma. After obtaining informed consent from the patient's by-standers, over a period of time, several types of case-based problems were constructed. The data thus collected were utilized in creating a workbook for FCTM and a set of problems for CBL. Students who are in the 5th and/or 6th year of Pharm. D course were invited to participate in the study after receiving information consent. A predosage calculation test was conducted after dividing the participants into two groups of equal numbers. Calculators were allowed. CBL approach for improving drug dose calculation skills was followed for one group of students and FCTM for the other group. In CBL approach, the students were exposed to several clinical problems for a given period, and then they were allowed to use any source of reference to understand the problems. In the FCTM, the students were provided with a workbook, which they should learn and understand by themselves. The workbook contains several worked examples and problem sets that the students could use to work out the concepts. Both the group of participants were asked to take a postdosage calculation test. It was a 1-h test session that contained clinical problems of pediatric dose calculation.

The effectiveness of both the teaching–learning strategies in improving pediatric drug dose calculation skills of the students was evaluated by comparing the pre and postdosage calculation test scores obtained from both the group of students using Paired t-test. A Z-test was used for comparing CBL and FCTM.

  Results Top

The data were collected from 100 consecutive admissions to the pediatric ward, of which 49 were male patients. The average age of the population studied was 8.18 ± 4.16 (0–18 years); the mean period of hospitalization was 7.7 ± 4.81 (1–19 days). Principal diagnosis includes viral pyrexia (6.92%), atrial septal defect (6.92%), ventricular septal defect (5.38%), fever (5.38%), head injury (4.61%), seizure (4.61%), and several others. The therapeutic category of drugs prescribed consisted of a total of 15 classes of drugs. The primary therapeutic category of drugs prescribed was antimicrobials (21.4%), nonsteroidal anti-inflammatory agents (17.70%), intravenous (IV) fluids (11.63%), antiepileptics (7.70%), cardiovascular drugs (7.37%), and several others.

The major routes were oral (54.16%), parenteral (34.02%), inhalation (6.25%), and topical (3.47%). Forty-nine (34.02%) of parenterally prescribed medications were administered through IV route, of these 41 (83.67%) were administered as IV infusions, while 5 (10.20%) were administered as IV bolus injections. The drugs commonly prescribed as tablets were aspirin (21.17%), clobazam (9.41%), paracetamol (7.05%), diazepam (4.70%), spironolactone (4.70%), and several others. The drugs commonly prescribed as syrups were paracetamol (20.30%), triclofos (9.70%), ibuprofen (4.85%), levetiracetam (4.85%), and several others.

Most frequently administered IV bolus injections were hydrocortisone (50%), midazolam (20%), hyoscine butyl bromide (10%), ketorolac (10%), and protamine (10%). The drugs administered as IV infusions include paracetamol (13.73%), ceftriaxone (11.64%), ondansetron (9.25%), dextrose normal saline (8.05%), and several others [Table 1].
Table 1: Types of dosage calculations

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[Figure 1] and [Figure 2] represent the scores obtained and statistical significance in predosage calculation test and postdosage calculation test from CBL and FCTM groups of students, respectively. The pre and postdosage calculation test scores were compared using a paired-t- test [Table 2] and [Table 3]. The mean of predosage calculation test scores was 10.67 (standard deviation [SD] = 5.235) and has increased to 20.73 (SD = 3.258) in the postdosage calculation test in the CBL group, t-value of 9.261 was obtained (P < 0.05), and the differences in the test scores were significant. Furthermore, the mean of predosage calculation test scores was 19 (SD = 4.948) and has increased to 21.40 (SD = 3.024) in the postdosage calculation test in the FCTM group; t-value of 2.485 was obtained (P < 0.05) and was found to be significant. The overall postdosage calculation test scores were seen to have improved significantly. The means of differences in the pre- and post-dosage calculation tests from CBL and FCTM groups of students were compared using z-test [Table 4]. The z- stat value was more significant than z-critical value (5.27 > 1.96) and so the means of differences in scores from the two teaching strategies differ significantly. [Figure 3] is a representation of the comparison of the mean test scores from CBL and FCTM.
Table 2: Paired samples test – case-based learning

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Table 3: Paired samples test – flipped classroom teaching model

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Table 4: Z- test: Two samples for means

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Figure 1: Scores obtained in predosage calculation and postdosage calculation tests: Case-based learning

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Figure 2: Scores obtained in pre-dosage calculation and postdosage calculation tests: Flipped classroom teaching model

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Figure 3: Comparisons of the mean test scores from case-based learning and flipped classroom teaching model

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  Discussion Top

Pediatric drug dose calculation skills can be improved by effective teaching–learning strategies among Pharm. D students. Literature has shown a significant concern about drug dosage calculation proficiency and the threat to patient safety. The objective of this study was to assess drug dosage calculation proficiency of 5th and 6th year Pharm. D students. The students were given the confidence and assured that this study was to improve their knowledge and skills related to drug dosage calculation, as it is an essential skill required for pharma students and so they need not worry about their scores in a pretest. They were explained that a well-designed teaching strategy would be provided to them to develop their competence in drug dosage calculation, enabling them for safe and accurate pediatric medication dose calculation.

The students found to be very enthusiastic about learning the drug dosage calculation proficiency that motivated them to participate in the informed consent process. The participants gave positive feedback that this was the first time they attended such a teaching–learning program to build their competence in drug dosage calculation. During the time of the program, the participants took very high interest to learn the mathematical concepts, different types of drug dose calculations in pediatrics, and formulae to be used for each type of drug dosage calculation. In the postdosage calculation test, a majority of the students (n = 60) performed well, showing that there was a significant impact on teaching strategies. The Pharm. D curriculum must address the students' need for developing skills in drug dosage calculation.

It is essential to assess the competency of Pharm. D students in drug dosage calculation, as it is vital to deliver safe and quality pharmaceutical care. Furthermore, we can control preventable medication errors and adverse events by reducing the chance of error by developing competence in drug dosage calculation. Moreover, we can provide cost-effective treatment by reducing the length of stay in the hospital. Finally, we can gain public trust through provision of error-free care or reduced medication error rate.[10]

The study results suggested that at the commencement of the study, the drug dosage calculation skills were weak among the students. Drug dosage calculation proficiency must be included in the basic curriculum to acquire the knowledge of drug dosage calculation. The study findings support that Pharm. D curriculum needs to be reviewed, keeping in mind the importance of drug dosage calculations. Several studies have demonstrated the significance of using different teaching–learning strategies over the traditional approaches used to teach calculations in pharmacy students.[17],[18],[19],[20],[21],[22],[23],[24]

Jacob et al. carried out a study “Evaluate the perceptions of lecturers on CBL and generate feedback and opinions on the design of CBL sessions in the pharmacy curricula.” Some of the specific benefits of CBL identified by participants during this study was the applicability of knowledge learned in students' future role as pharmacists.[25] Rebitch et al. designed and developed a series of technology-enhanced, CBL activities framed by the Pharmacists' Patient Care Process (PPCP) and evaluated the impact of these activities on student perceptions and performance. The use of technology-enhanced, case-based modules based on a standardized patient care process resulted in positive student perceptions and improved patient case assessment scores.[26]

Nutan and Demps conducted an online assessment, in which individualized question sets were randomly constructed from a question pool containing multiple-choice questions and presented as online homework. This approach was evaluated by comparing the overall grades. Students preferred the online homework assignments.[19] Rutter and Watts conducted a study that showed the importance of proactive strategies comprising blended learning approaches in improving both confidence and competence in performing pharmaceutical calculations.[20] This study has shown evidence for the CBL and FCTM to have a positive impact. The pre- and post-dosage calculation test clearly showed significant improvement in scores after CBL and FCTM. Although both methods resulted in improvement of drug dose calculation skills after the exposure, the CBL method was statistically superior to the FCTM. The study shows that any educational strategy gives a positive outcome, regardless of the method. FCTM works well when compared with no other intervention, but when tested against conventional methods such as CBL, it is difficult to detect any large-scale differences.

  Conclusion Top

This study helped evaluate the significant improvement in students' performance. It indicates the effectiveness of these two strategies for teaching drug dose calculations. It was found that CBL had a more significant impact than the FCTM in improving the drug dose calculation skills of Pharm. D students. It can be used to adopt effective strategies for teaching–learning of dosage calculation in Pharm. D students.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rowe C, Koren T, Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child 1998;79:56-8.  Back to cited text no. 1
Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990;47:533-43.  Back to cited text no. 2
Simonsen BO, Daehlin GK, Johansson I, Farup PG. Improvement of drug dose calculations by classroom teaching or e-learning: A randomised controlled trial in nurses. BMJ Open 2014;4:e006025.  Back to cited text no. 3
Prince MD. A study to assess the effectiveness of plannedteaching programme onpediatric drug dose calculation among fourth year B. Sc nursing students in a selected nursing colleges in hyderabad. 2015;10:10-3.  Back to cited text no. 4
Hoyle JD, Davis AT, Putman KK, Trytko JA, Fales WD. Medication dosing errors in pediatric patients treated by emergency medical services. Prehosp Emerg Care 2012;16:59-66.  Back to cited text no. 5
Ghaleb MA, Barber N, Franklin BD, Wong IC. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child 2010;95:113-8.  Back to cited text no. 6
Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003;111:722-9.  Back to cited text no. 7
Wheeler DW, Remoundos DD, Whittlestone KD, House TP, Menon DK. Calculation of doses of drugs in solution: Are medical students confused by different means of expressing drug concentrations? Drug Saf 2004;27:729-34.  Back to cited text no. 8
Harrap N, Usman S, McLoughlin C, Orwell S, Harris SA, Ling V, et al. Using a blended approach to support calculation skills of pharmacy students. Pharm Educ 2016;16:189-98.  Back to cited text no. 9
Sultana N. An evaluation of drug dosage calculation knowledge and proficiency among newly hired nurses in private tertiary care hospital, Islamabad, Pakistan. Texila Int J Clin Res 2017;4:103-17.  Back to cited text no. 10
Huse JS. Comparison of teaching strategies on teaching drug dosage calculation skills in fundamental nursing students. Comp Teach Strateg Teach Drug Dos Calc Ski Fundam Nurs Students 2010;345:345. Available from: http://search. ebscohost. com/login. aspx? direct=true&db=cin20&AN=109853910&site=ehost-live&scope=site.  Back to cited text no. 11
Saleem Z, Tabassum N, Asif N. Case based scenarios: Evidence based teaching learning strategy in nursing education pharmacology course. Int J Nurs 2014;1:147-54. Available from: http://dx. doi.org/DOI.  Back to cited text no. 12
Williams B. Case based learning-A review of the literature: Is there scope for this educational paradigm in prehospital education? Emerg Med J 2005;22:577-81.  Back to cited text no. 13
Bishop JL, Verleger MA. The flipped classroom: A survey of the research. ASEE Annu Conf Expo Conf Proc; 2013.  Back to cited text no. 14
Das B, Sarkar C. An innovative flipped class intervention to improve dose calculation skills of Phase I medical students: A preliminary study. Procedia-Soc Behav Sci 2015;182:67-74. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1877042815030141.  Back to cited text no. 15
Persky AM, McLaughlin JE. The flipped classroom – From theory to practice in health professional education. Am J Pharm Educ 2017;81:118.  Back to cited text no. 16
McQueen DS, Begg MJ, Maxwell SR. eDrugCalc: An online self-assessment package to enhance medical students' drug dose calculation skills. Br J Clin Pharmacol 2010;70:492-9.  Back to cited text no. 17
Bergen P, McDowell J, Elliott RA, Roller L, Kong D. Development of an online pharmaceutical calculations learning module. Pharm Educ 2011;11:21-5.  Back to cited text no. 18
Nutan MT, Demps EL. Online assessments in pharmaceutical calculations for enhancing feedback and practice opportunities. Curr Pharm Teach Learn 2014;6:807-14.  Back to cited text no. 19
Rutter PM, Watts A. Introduction of a pharmaceutical calculations strategy to first year MPharm students. Pharm Educ 2010;10:157-64.  Back to cited text no. 20
Hasamnis A, Arya A, Patil S. Case-based learning: Our experience in clinical pharmacology teaching. Pharm Bioallied Sci 2019;11:187-9.  Back to cited text no. 21
Cotta KI, Shah S, Almgren MM, Macías-Moriarity LZ, Mody V. Effectiveness of flipped classroom instructional model in teaching pharmaceutical calculations. Curr Pharm Teach Learn 2016;8:646-53. Available from: http://dx.doi.org/10.1016/j.cptl. 2016.06.011.  Back to cited text no. 22
Røe Y, Rowe M, Ødegaard NB, Sylliaas H, Dahl-Michelsen T. Learning with technology in physiotherapy education: Design, implementation and evaluation of a flipped classroom teaching approach. BMC Med Educ 2019;19:291.  Back to cited text no. 23
Hu X, Zhang H, Song Y, Wu C, Yang Q, Shi Z, et al. Implementation of flipped classroom combined with problem-based learning: An approach to promote learning about hyperthyroidism in the endocrinology internship. BMC Med Educ 2019;19:290.  Back to cited text no. 24
Jacob SA, Dhing OH, Malone D. Perceptions of Australian and Malaysian educators in an undergraduate pharmacy program on case-based learning. Am J Pharm Educ 2019;83:6597.  Back to cited text no. 25
Rebitch CB, Fleming VH, MEd RP, Rong H, Choi I. Evaluation of video-enhanced case-based activities guided by the pharmacists' patient care process. Am J Pharm Educ 2019;83:6676.  Back to cited text no. 26


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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