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Published on: June 11, 2012
Potential future risk of errors in medication administration recording
Noelia Vicente Oliveros1, Covadonga Pérez Menendez-Conde2, Teresa Gramage Caro2
1Department of Pharmacy, Hospital Universitario Ramón y Cajal, Madrid, Spain. noelia.vicente@salud.madrid.org.
Rationale, Aims And Objectives:
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 The definition of each grade of likelihood of recurrence was based on the incidence of ME-MAR from an unpublished study carried out in our hospital.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).
Conclusion:
The adapted matrix of potential future risk to ME-MAR is reliable and can serve as a guide for future studies.
Insights
This study adapted a risk matrix for medication errors in medication administration recording (ME-MAR). The adapted matrix demonstrated substantial interrater reliability, proving useful for future research.
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.
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