title: Potential future risk of errors in medication administration recording.
abstract: OBJECTIVE
  The aim of this study is to adapt and assess the interrater reliability of a potential future risk matrix for medication errors in medication administration recording (ME-MAR).
  
  
  METHODS
  The study was carried out in a teaching hospital. It was conducted in two phases. In the first phase, a consensus method was used in order to adapt the potential future risk matrix published by the National Patient Safety and Otero et al. to the ME-MAR. The consensus method consisted in a nominal group formed by four pharmacists. In the second phase, a multidisciplinary group of experts in patient safety assessed the reliability of the adapted matrix. Five raters evaluated 100 ME-MAR. Its reliability was evaluated using the kappa statistic.
  
  
  RESULTS
  In the first phase, two meetings were necessary until consensus was reached to adapt the potential future risk matrix to the ME-MAR. For this purpose, the two following categories were defined: likelihood of ME-MAR's recurrence and most likely consequences of ME-MAR. The definition of each grade of likelihood of recurrence was based on the incidence of ME-MAR from an unpublished study carried out in our hospital. In order to determine the most likely consequences of ME-MAR, a two-dimensional matrix was designed, with severity per type of ME-MAR on one axis and the class of medication on the other. In the second phase, the reliability of the matrix was tested. The overall interrater agreement for the five raters was substantial at 0.68 (Confidence interval 95% 0.60-0.76).
  
  
  CONCLUSIONS
  The adapted matrix of potential future risk to ME-MAR is reliable and can serve as a guide for future studies.
authors.affiliation: Department of Pharmacy, Hospital Universitario Ramón y Cajal, Madrid, Spain. noelia.vicente@salud.madrid.org.
authors.forename: Noelia
authors.initials: N
authors.lastname: Vicente Oliveros
authors.affiliation: Department of Pharmacy, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Covadonga
authors.initials: C
authors.lastname: Pérez Menendez-Conde
authors.affiliation: Department of Pharmacy, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Teresa
authors.initials: T
authors.lastname: Gramage Caro
authors.affiliation: Department of Pharmacy, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Ana María
authors.initials: AM
authors.lastname: Álvarez Díaz
authors.affiliation: Department of Pharmacy, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Manuel
authors.initials: M
authors.lastname: Vélez-Díaz-Pallarés
authors.affiliation: Department of Geriatric Medicine, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Montero Errasquín
authors.affiliation: Department of Internal Medicine, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Gema
authors.initials: G
authors.lastname: Nieto Gómez
authors.affiliation: Department of General and Gastrointestinal surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Teresa
authors.initials: T
authors.lastname: Rodríguez Cubilot
authors.affiliation: Department of Pharmacology, Universidad Complutense de Madrid, Madrid, Spain.
authors.forename: Sagrario
authors.initials: S
authors.lastname: Martín-Aragón Álvarez
authors.affiliation: Department of Pharmacy, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Teresa
authors.initials: T
authors.lastname: Bermejo Vicedo
authors.affiliation: Department of Pharmacy, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Eva
authors.initials: E
authors.lastname: Delgado Silveira
mesh_terms: D006784:Hospitals, Teaching; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control*; D061214:Patient Safety; D055553:Prescription Drugs / Q000008:administration & dosage*; D018570:Risk Assessment / Q000379:methods
chemical_list: D055553:Prescription Drugs
keywords: medication administration record; medication error; nominal group; patient safety; potential future risk; risk matrix