Potential future risk of errors in medication administration recording.

Area of Science:

• Pharmacovigilance
• Patient Safety
• Risk Management

Background:

• Medication errors in medication administration recording (ME-MAR) pose a significant risk to patient safety.
• Existing risk assessment tools require adaptation to effectively evaluate ME-MAR.
• A reliable method is needed to predict and mitigate potential future risks associated with ME-MAR.

Purpose of the Study:

• To adapt an existing risk matrix for the specific context of medication errors in medication administration recording (ME-MAR).
• To assess the interrater reliability of the adapted risk matrix among healthcare professionals.
• To establish a dependable tool for evaluating and managing ME-MAR risks.

Main Methods:

• A two-phase study conducted in a teaching hospital.
• Phase 1: Consensus method involving four pharmacists to adapt the National Patient Safety risk matrix to ME-MAR.
• Phase 2: Multidisciplinary expert group assessed reliability using a 100 ME-MAR evaluation and kappa statistic.

Main Results:

• Consensus was reached after two meetings, defining likelihood of recurrence and most likely consequences for ME-MAR.
• A two-dimensional matrix was developed, considering severity, ME-MAR type, and medication class.
• The adapted matrix showed substantial overall interrater agreement (kappa = 0.68, 95% CI 0.60-0.76).

Conclusions:

• The adapted risk matrix for ME-MAR is reliable.
• This tool can serve as a valuable guide for future research and risk assessment in medication administration.
• The study supports the use of this matrix for enhancing patient safety.