Tecnologia computacional e participação do paciente na segurança medicamentosa: revisão integrativa / Computational technology and patient participation in medication safety: integrative review / Tecnología computacional y participación del paciente en la seguridad de los medicamentos: revisión integradora

Objetivou-se investigar as tecnologias computacionais utilizadas para a participação do paciente no tocante à segurança medicamentosa em ambiente hospitalar. Trata-se de uma revisão integrativa realizada entre julho a dezembro de 2022, sem recorte temporal, nas bases de dados Web of Science, CINAHL e MedLINE. Os resultados consistiram em 117 artigos, dos quais 16 foram incluídos no estudo. Verificou-se que as tecnologias computacionais desenvolvidas foram: aplicativos móveis, plataformas interativas e prontuário eletrônico. Destaca-se que o tablet foi o recurso mais utilizado para o acesso das informações pelos pacientes, e que estes apresentaram satisfação moderada a elevada quanto ao uso do equipamento. No tocante ao sistema de medicação, verificou-se que oito publicações citavam que o respectivo produto tecnológico testado era específico à etapa de administração dos medicamentos, duas na prescrição e administração, e apenas uma integrava pelo menos três etapas, a saber: prescrição, dispensação e administração. Conclui-se que a participação do paciente se dá mediada por aplicativos móveis via tablet, evidenciando possibilidades para melhorar a segurança medicamentosa durante a internação hospitalar.

The objective was to investigate the computational technologies used for patient participation regarding drug safety in a hospital environment. This is an integrative review carried out between July and December 2022, without a time frame, in the Web of Science, CINAHL and MedLINE databases. The results consisted of 117 articles, of which 16 were included in the study. It was found that the computational technologies developed were: mobile applications, interactive platforms and electronic medical records. It is noteworthy that the tablet was the most used resource for accessing information by patients, and that they showed moderate to high satisfaction with the use of the equipment. With regard to the medication system, it was found that eight publications mentioned that the respective technological product tested was specific to the medication administration stage, two in the prescription and administration, and only one integrated at least three stages, namely: prescription, dispensing and administration. It is concluded that the patient's participation is mediated by mobile applications via tablet, highlighting possibilities to improve medication safety during hospitalization.

El objetivo fue investigar las tecnologías computacionales utilizadas para la participación del paciente en relación con la seguridad de los medicamentos en un entorno hospitalario. Se trata de una revisión integradora realizada entre julio y diciembre de 2022, sin marco temporal, en las bases de datos Web of Science, CINAHL y MedLINE. Los resultados consistieron en 117 artículos, de los cuales 16 fueron incluidos en el estudio. Se encontró que las tecnologías computacionales desarrolladas fueron: aplicaciones móviles, plataformas interactivas e historias clínicas electrónicas. Cabe destacar que la tableta fue el recurso más utilizado para acceder a la información por parte de los pacientes, y que éstos mostraron una satisfacción de moderada a alta con el uso del equipo. Con relación al sistema de medicación, se encontró que ocho publicaciones mencionaron que el respectivo producto tecnológico probado era específico para la etapa de administración de medicamentos, dos en la prescripción y administración, y sólo una integró por lo menos tres etapas, a saber: prescripción, dispensación y administración. Se concluye que la participación del paciente está mediada por aplicaciones móviles a través de tablet, destacando las posibilidades de mejorar la seguridad de la medicación durante la hospitalización.

Conciliação medicamentosa na admissão de pacientes transplantados renais em um hospital universitário / Medication reconciliation in the admission of kidney transplant patients to a university hospital

Introdução:O presente estudo considerou conciliações medicamentosas realizadas na admissão hospitalar de pacientes transplantados renais e intervenções farmacêuticas decorrentes desse processo.Métodos:Trata-se de um estudo transversal realizado no período de julho de 2018 a julho de 2019 no Hospital de Clínicas de Porto Alegre. Foram coletadas as características dos pacientes, as conciliações medicamentosas realizadas pelo farmacêutico clínico, as discrepâncias identificadas pelo mesmo (intencionais e não intencionais) e o resultado das intervenções. Os medicamentos foram classificados de acordo com a Anatomic Therapeutic Chemical (ATC).Resultados:Dos 719 pacientes acompanhados pelo farmacêutico clínico, 175 tiveram a conciliação medicamentosa de admissão realizada, desses, 56 apresentaram discrepâncias não intencionais. Encontramos a média de 2,2 medicamentos omissos por prescrição com desvio padrão de 1,3 medicamentos. No total, foram realizadas 122 intervenções farmacêuticas, sendo que em 61,5% houve adesão por parte da equipe médica. A classe terapêutica com maior ocorrência (43,4%) de discrepâncias não intencionais foi a que atuava sobre o aparelho cardiovascular. As variáveis observadas foram sexo, número de medicamentos nas intervenções (ambas com associação significativa com a adesão médica), idade, tempo de internação, número de medicamentos na internação e número de medicamentos de uso prévio (estas últimas sem associação significativa com a adesão médica). Conclusões:A conciliação medicamentosa previne possíveis erros de medicação, uma vez que a identificação das discrepâncias não intencionais na prescrição médica gera sinalizações que são levadas pelo farmacêutico clínico à equipe assistente, a fim garantir o uso seguro e correto dos medicamentos durante a internação hospitalar.

Introduction:This study considered medication reconciliations performed on hospital admission of kidney transplant patients and pharmaceutical interventions resulting from this process.Methods:This is a cross-sectional study carried out from July 2018 to July 2019 at Hospital de Clínicas de Porto Alegre. The characteristics of the patients, the medication reconciliations performed by the clinical pharmacist, the discrepancies identified by the same (intentional and unintentional) and the result of the interventions were collected. The drugs were classified according to the Anatomic Therapeutic Chemical (ATC). Results:Of the 719 patients monitored by the clinical pharmacist, 175 had medication reconciliation on admission performed, of which 56 had unintentional discrepancies. We found an average of 2.2 missing medications per prescription with a standard deviation of 1.3 medications. In total, 122 pharmaceutical interventions were performed, and in 61.5% there was adherence by the medical team. The therapeutic class with the highest occurrence (43.4%) of unintentional discrepancies was that which acted on the cardiovascular system. The variables observed were gender, number of medications in interventions (both with a significant association with medical adherence), age, length of stay, number of medications in hospitalization and number of medications previously used (the latter without a significant association with medical adherence).Conclusions:Medication reconciliation prevents possible medication errors, since the identification of unintentional discrepancies in the medical prescription generates signals that are taken by the clinical pharmacist to the assistant team, in order to guarantee the safe and correct use of medications during hospitalization.

Perfil das Discrepâncias Obtidas por meio da Conciliação Medicamentosa em Pacientes Oncológicos: Revisão Integrativa da Literatura / Profile of the Medication Reconciliation Discrepancies in Oncology Patients: Integrative Literature Review / Perfil de las Discrepancias Obtenidas por la Conciliación de Medicamentos en Pacientes Oncológicos: Revisión Integradora de la Literatura

Introdução: O cuidado ao paciente oncológico demanda ações de uma equipe multiprofissional em virtude da complexidade do seu tratamento. Um dos serviços oferecidos pelo farmacêutico, visando a contribuir para segurança do paciente, é a conciliação medicamentosa capaz de detectar discrepâncias nas prescrições e prevenir erros de medicação. Objetivo: Traçar o perfil das principais discrepâncias encontradas na literatura em pacientes oncológicos durante a prática da conciliação medicamentosa realizada por farmacêuticos. Adicionalmente, visa-se a uma abordagem descritiva sobre as intervenções farmacêuticas realizadas nos estudos. Método: Revisão integrativa da literatura. Foram utilizados os descritores: "Medication Reconciliation", "Neoplasms", "Pharmacists", "Medication Errors" para as estratégias de busca. As bases de dados selecionadas foram: PubMed, Web of Science, Embase e Scopus. Resultados: Inicialmente, identificaram-se 141 artigos. Destes, foram selecionados 11 trabalhos para serem discutidos. A conciliação medicamentosa foi realizada em pacientes na admissão hospitalar (27,3%), alta hospitalar (18,2%), e acompanhamento ambulatorial (54,5%). A maior parte era de estudos observacionais (72,7%) seguidos dos estudos de intervenção (27,3%). A principal discrepância relatada foi a de omissão/necessidade de adição de um medicamento (81,5%). As intervenções farmacêuticas estavam descritas mais detalhadamente em 36,4% das publicações. Conclusão: O estudo demonstrou a necessidade de mais trabalhos que correlacionem a prática da conciliação medicamentosa com a detecção de discrepâncias e intervenções farmacêuticas em Oncologia. Os farmacêuticos, objetivando a segurança do paciente, devem estruturar essa prática na vivência clínica dos pacientes oncológicos

Introduction: Cancer patient care requires actions of a multi-professional team due to the complexity of the treatment. One of the pharmacist's services to contribute for the patient safety is the medication reconciliation, able to detect discrepancies in prescriptions and preventing medication errors. Objective: Draw a profile of the main discrepancies found in the literature in cancer patients during the practice of medication reconciliation performed by pharmacists. Additionally, a descriptive approach of the pharmaceutical interventions found in the studies was also attempted. Method: Integrative review of the literature with descriptors "Medication Reconciliation", "Neoplasms", "Pharmacists", "Medication Errors" utilized to search in the following databases: PubMed, Web of Science, Embase and Scopus. Results: Initially, 141 articles were found and eleven were selected for discussion. Medication reconciliation was performed in patients at admission (27.3%), discharge from hospital (18.2%), and outpatient follow-up (54.5%). Observational Studies were the majority (72.7%) followed by intervention studies (27.3%). The main discrepancy reported was Omission/Need to add a medicine (81.5%). Pharmaceutical interventions were described in more detail in 36.4% of the publications. Conclusion: This study demonstrates the need for more articles that correlates the practice of medication reconciliation with the detection of discrepancies and pharmaceutical interventions in Oncology. Pharmacists should structure the practice of medication reconciliation in the clinical experience with cancer patients to improve their safety

Introducción: La atención a los pacientes con cáncer exige las acciones de un equipo multidisciplinario debido a la complejidad de su tratamiento. Uno de los servicios ofrecidos por el farmacéutico para contribuir a la seguridad del paciente es la conciliación de medicamentos, capaz de detectar discrepancias en las recetas y prevenir errores de medicación. Objetivo: Obtener un perfil de las principales discrepancias encontradas en la literatura en pacientes con cáncer durante la práctica de conciliación de medicamentos realizada por farmacéuticos. Además, también está dirigido a un enfoque descriptivo sobre las intervenciones farmacéuticas llevadas a cabo en los estudios. Método: Estudio de revisión integradora. Se ha utilizado los descriptores: "Medication Reconciliation", "Neoplasms", "Pharmacists", "Medication Errors" para las estrategias de búsqueda. Las bases de datos seleccionadas fueron: PubMed, Web of Science, Embase y Scopus. Resultados: Inicialmente, se encontraron 141 artículos. Se seleccionaron 11 documentos a ser discutidos. La conciliación de medicamentos se realizó en pacientes con ingreso hospitalario (27,3%), alta hospitalaria (18,2%) y seguimiento ambulatorio (54,5%). La mayoría fue de estudios observacionales (72,7%) seguidos de estudios de intervención (27,3%). La principal discrepancia reportada fue la Omisión/Necesidad de añadir un medicamento (81,5%). Las intervenciones farmacéuticas se describieron con más detalle en el 36,4% de las publicaciones. Conclusión: El estudio demostró la necesidad de más trabajos que correlacione la conciliación de la medicación con la detección de discrepancias e intervenciones farmacéuticas en Oncología. Los farmacéuticos que buscan la seguridad del paciente deben estructurar esta práctica clínica en la experiencia clínica de los pacientes con cáncer

Patients' medication reconciliation in a university hospital

Abstract Medication reconciliation is a strategy to minimize medication errors at the transition points of care. This study aimed to demonstrate the effectiveness of medication reconciliation in identifying and resolving drug discrepancies in the admission of adult patients to a university hospital. The study was carried out in a 300-bed large general public hospital, in which a reconciled list was created between drugs prescribed at admission and those used at pre-admission, adapting prescriptions from the pharmacotherapeutic guidelines of the hospital studied and the patients' clinical conditions. One hundred seven patients were included, of which 67,3% were women, with a mean age of 56 years. Two hundred twenty-nine discrepancies were found in 92 patients; of these, 21.4% were unintentional in 31.8% of patients. The pharmacist performed 49 interventions, and 47 were accepted. Medication omission was the highest occurrence (63.2%), followed by a different dose (24.5%). Thirteen (26.5%) of the 49 unintentional discrepancies included high-alert medications according to ISMP Brazil classification. Medication reconciliation emerges as an important opportunity for the review of pharmacotherapy at transition points of care, based on the high number of unintentional discrepancies identified and resolved. During the drug reconciliation process, the interventions prevented the drugs from being misused or omitted during the patient's hospitalization and possibly after discharge.

Acompanhamento clínico farmacêutico no cuidado ao paciente adulto-cirúrgico em um hospital universitário de Porto Alegre / Clinical pharmacist follow-up in adult surgical patient care in a university hospital of Porto Alegre

Introdução: O farmacêutico clínico já está bem estabelecido em algumas instituições e muitos serviços de saúde contam com este profissional em suas equipes, entretanto, poucos conseguem sistematizar o seu trabalho e mapear os dados das atividades desenvolvidas, demonstrando a relevância do profissional na equipe de saúde. O objetivo deste trabalho foi avaliar o acompanhamento clínico-farmacêutico em uma unidade de internação adulto-cirúrgica em um hospital universitário de Porto Alegre. Métodos: Estudo descritivo retrospectivo que quantificou as principais atividades do farmacêutico clínico em uma unidade de internação adulto-cirúrgica no período de janeiro a maio de 2019. Este projeto foi aprovado no Comitê de Ética em Pesquisa da referida instituição. Resultados: 859 pacientes foram admitidos na unidade cirúrgica avaliada, dos quais 490 foram revisados pelo farmacêutico na admissão hospitalar, correspondendo à taxa média de 57,27%. A taxa média de conciliação medicamentosa realizada foi de 14,83%, totalizando 73 pacientes conciliados por entrevista. 361 intervenções farmacêuticas foram realizadas no período estudado, sendo 54 relacionadas a conciliação medicamentosa, com o número total de adesões de 232. As principais especialidades cirúrgicas que internam pacientes na unidade em questão foram a Ortopedia, Cirurgia do Aparelho Digestivo, Urologia e Cirurgia Vascular. Conclusões: Foi possível avaliar o acompanhamento clínico farmacêutico em uma unidade de internação adulto-cirúrgica em um hospital universitário de Porto Alegre, através da quantificação das taxas de pacientes revisados e de conciliação medicamentosa, do número de intervenções farmacêuticas e suas adesões, além de caracterizar as principais especialidades médicas cirúrgicas envolvidas. (AU)

Introduction: Clinical pharmacists are already well established in some institutions, and many health services have these professionals in their teams. However, few are able to systematize their work and map data from the developed activities, demonstrating the relevance of these professionals in the health team. This study aimed to evaluate the clinical pharmacist follow-up in an adult surgical inpatient unit in a university hospital in Porto Alegre. Methods: This is a retrospective, descriptive study that quantified the main activities of the clinical pharmacist in an adult surgical inpatient unit from January to May 2019. This project was approved by the Research Ethics Committee of the institution. Results: Of 859 patients admitted to the s rgical unit, 490 were reviewed by the pharmacist on hospital admission, corresponding to an average rate of 57.27%. The average medication reconciliation rate was 14.83%, totaling 73 patients reconciled per interview. Of 361 pharmaceutical interventions performed during the study period, 54 were related to medication reconciliation, and the total number of adhesions was 232. The main surgical specialties associated with admission to the study unit were Orthopedics, Digestive System Surgery, Urology, and Vascular Surgery. Conclusions: It was possible to evaluate the clinical pharmacist follow-up in an adult surgical inpatient unit in a university hospital in Porto Alegre by quantifying the rates of reviewed patients and medication reconciliations as well as the number of pharmaceutical interventions and their adherences, in addition to characterizing the main medical-surgical specialties involved. (AU)

Medication discrepancies in a hospital in Southern Brazil: the importance of medication reconciliation for patient safety

Medication discrepancies are of great concern in hospitals because they pose risks to patients and increase health care costs. The aim of this study was to estimate the prevalence of inconsistent medication prescriptions to adult patients admitted to a hospital in southern Santa Catarina, Brazil. This was a patient safety study on patients recruited between November 2015 and June 2016. The participants were interviewed and had their medical records reviewed. Discrepant medications were considered those that did not match between the list of medicines taken at home and the prescribed drugs for treatment in a hospital setting. Of the 394 patients included, 98.5% took continuous-use medications at home, with an average of 5.5 medications per patient. Discrepancies totaled 80.2%, The independent variables associated with the discrepancies were systemic arterial hypertension, hypercholesterolemia, vascular disease, number of medications taken at home, and poor documentation of the medications in the medical record. Findings from this study allowed us to conclude there was a high rate of prescription medication misuse. Medication reconciliation is crucial in reducing these errors. Pharmacists can help reduce these medication-related errors and the associated risks and complications.

Conciliação Medicamentosa em Cuidados Paliativos Oncológicos / Medication Reconciliation in Oncologic Palliative Care / Conciliación de la Medicación en Cuidados Paliativos Oncológicos

Introdução: A ausência de informações a respeito dos medicamentos utilizados pelos pacientes pode causar erros de medicações. Assim, a comunicação entre profissionais de saúde, pacientes e familiares é primordial para a segurança do paciente nos diferentes níveis de atenção à saúde. Os farmacêuticos clínicos podem realizar a conciliação de medicamentos e atuar em colaboração com outros profissionais, objetivando otimizar a farmacoterapia e melhorar a segurança do paciente. As pessoas sob Cuidados Paliativos costumam fazer uso de polifarmácia e, quando não acompanhadas pelos profissionais de saúde, estão susceptíveis a potenciais discrepâncias não intencionais causadas por comunicação inadequada. Objetivo: Analisar o perfil das conciliações medicamentosas em pacientes que estão sob Cuidados Paliativos Oncológicos. Método: Estudo transversal, analítico e descritivo. Foram analisadas todas as visitas de conciliações realizadas na admissão dos pacientes, na unidade IV do Instituto Nacional de Câncer José Alencar Gomes da Silva (HCIV/INCA), no período de junho a novembro de 2018. Resultados: Realizaram-se 194 visitas, nas quais foram identificadas 1.770 discrepâncias (78,2%), sendo 93,8% intencionais, 0,7% intencionais documentadas e 5,4% não intencionais. Todas as prescrições apresentaram pelo menos uma discrepância e 34,6% foram totalmente modificadas pelo prescritor no ato da admissão. Foram realizadas 112 intervenções farmacêuticas relacionadas à conciliação medicamentosa. Conclusão: As principais discrepâncias encontradas, inclusão de medicamentos e ajustes de dose ressaltam a importância da presença de farmacêuticos clínicos no momento da admissão do paciente, em que foi possível ajustar a farmacoterapia, em conjunto com corpo clínico, contribuindo para a melhoria do perfil de prescrição

Introduction: The lack of information about the medications used by the patient can cause medication errors, so communication between health professionals, patients and family members is paramount for patient safety at different levels of attention to health. Clinical pharmacists can perform drug reconciliation and work in collaboration with other professionals to optimize pharmacotherapy and improve the patient's safety. Patients in Palliative Care tend to use polypharmacy, and when not accompanied by health professionals are susceptible to potential unintentional discrepancies caused by poor communication. Objective: To analyze the characteristics of the profile of drug reconciliations in patients who are under Oncologic Palliative Care. Method: Cross-sectional, analytical, and descriptive study. All the reconciliation visits performed at the admission of the patients were analyzed in the hospitalization unit of the National Cancer Institute José Alencar Gomes da Silva (HCIV/INCA), from June to November 2018. Results: A total of 194 visits were conducted, where 1,770 discrepancies (78.2%) were found, 93.8% intentional, 0.7% intentional documented and 5.4% unintentional. All the prescriptions presented at least one discrepancy and 34.5% were totally modified by the prescriber on admission. There were 112 pharmaceutical interventions related to medication reconciliation. Conclusion: The main discrepancies found, inclusion of drugs and dose adjustments, highlights the importance of the presence of clinical pharmacists at the time of the patient's admission, when it was possible to adjust pharmacotherapy, together with the clinical staff and contributing to the improvement of the prescription profile

Introducción: La falta de información sobre los medicamentos utilizados por el paciente puede generar errores de medicación, por lo que la comunicación entre los profesionales de la salud, los pacientes y los familiares es fundamental para la seguridad del paciente en los diferentes niveles de atención. Los farmacéuticos clínicos pueden realizar la conciliación de fármacos y trabajar en colaboración con otros profesionales para optimizar la farmacoterapia y mejorar la seguridad del paciente. Las personas que reciben Cuidados Paliativos suelen utilizar la polifarmacia y, cuando no están acompañadas de profesionales de la salud, son susceptibles a posibles discrepancias no intencionadas provocadas por una comunicación inadecuada. Objetivo: Analizar el perfil de las conciliaciones de fármacos en pacientes que se encuentran en Cuidados Oncológicos Paliativos. Método: Estudio transversal, analítico y descriptivo. Se analizaron todas las visitas de conciliación realizadas al ingreso de pacientes en la unidad de internación del Instituto Nacional del Cáncer José Alencar Gomes da Silva (HCIV/ INCA), de junio a noviembre de 2018. Resultados: Se realizaron 194 visitas, durante las cuales Se identificaron 1.770 discrepancias (78,2%), de las cuales 93,8% fueron intencionales, 0,7% fueron documentadas y 5,4% fueron no intencionales. Todas las prescripciones mostraron al menos una discrepancia y el 34,5% se modificó por completo por el prescriptor al ingreso. Se realizaron 112 intervenciones farmacéuticas relacionadas con la conciliación de fármacos. Conclusión: Las principales discrepancias encontradas, inclusión de medicamentos y ajustes de dosis, resaltan la importancia de la presencia de farmacéuticos clínicos en el momento del ingreso del paciente, donde fue posible ajustar la farmacoterapia, junto con el personal clínico y contribuyendo a la mejora clínica de la prescripción

Reconciliação de medicamentos: processo de implantação em um complexo hospitalar com a utilização de sistema eletrônico / Medication reconciliation: implantation process in a hospital complex with the use of electronic system

RESUMO Este estudo avaliou a implantação da reconciliação de medicamentos em um hospital multibloco, filantrópico e de ensino com a utilização de um sistema eletrônico para realizar o registro da atividade com atuação multiprofissional. Foram capacitados 438 profissionais da enfermagem sobre a reconciliação de medicamentos. De outubro de 2017 a março de 2018, foram registradas pelo enfermeiro, no prontuário eletrônico, a informação sobre uso prévio de medicamentos para 1.379 pacientes. Foram reconciliados pelo farmacêutico apenas 347 destes registros, sendo que 106 precisaram de intervenção com médico prescritor. O número de pacientes que tiveram o medicamento informado como de uso prévio prescrito sem nenhuma alteração foi de 180, os que tiveram o medicamento prescrito com alguma alteração foram 47, e os que não possuíam os medicamentos informados prescritos foram 106. A utilização de sistemas informatizados pode ser útil para as equipes executarem a reconciliação medicamentosa, mas depende da correta utilização do sistema e treinamento das equipes. O acompanhamento diário do farmacêutico clínico aumenta a segurança do paciente quanto ao uso de medicamentos dentro dos hospitais, entretanto, para executar a atividade, é necessário realizar algumas medidas de melhoria para obter o cumprimento da reconciliação de medicamentos dos pacientes na sua totalidade.

ABSTRACT This study evaluated the implementation of medication reconciliation in a philanthropic, teaching, and multi-block hospital with the use of an electronic system to record the multidisciplinary activity. A total of 438 nursing professionals were trained on medication reconciliation. From October 2017 to March 2018, the information about previous use of drugs for 1,379 patients was registered by the nurse in the electronic system. Only 347 of those records were reconciled by the pharmacist, and 106 needed intervention of the prescribing doctor. The number of patients who had the medication prescribed without any change was 180, 47 had the medication prescribed with some change, and 106 did not have the prescribed the medications of previous use. The use of computerized systems can be useful for the teams to perform medication reconciliation, but it depends on the correct use of the system and training of the teams. The daily follow-up of the clinical pharmacist increases patient safety regarding the use of drugs within the hospitals, but to perform the activity some improvement measures are necessary to obtain compliance with the patients' medication reconciliation in their entirety.

Profile of drugs used for self-medication by elderly attended at a referral center / Perfil de medicamentos utilizados por automedicação por idosos atendidos em centro de referência

ABSTRACT Objective To determine the profile of medications used for self-medication by the elderly. Methods A cross-sectional study based on interviews with elderly seen at a reference center for Elderly Health of a teaching hospital, from July 2014 to July 2015. Clinical, demographic and pharmacotherapeutic data were collected. Results A total of 170 elderly were interviewed, 85.9% female, and the median age was 76 years. The frequency of self-medication was 80.5%. The most used medications for self-medication were central acting muscle relaxants, analgesics and antipyretics, non-steroidal anti-inflammatory and antirheumatic agents. Among the elderly who practiced self-medication, 55.5% used drugs that were inappropriate for the elderly, according to Beers criteria of 2015, and 56.9% used medications that showed therapeutic duplicity with the prescribed drugs. We identified 57 drugs used for self-medication, of which 30 (52.6%) were classified as over-the-counter and 27 (47.4%) as prescription drugs. Approximately 68.6% of elderly had at least one interaction involving drugs prescribed and those used for self-medication. Conclusion The practice of self-medication was frequent in the elderly studied. The widespread use of over-the-counter drugs and/or potentially inappropriate medications for elderly increases the risk of drug interactions and adverse events.

RESUMO Objetivo Determinar o perfil dos medicamentos utilizados por automedicação por idosos. Métodos Estudo transversal baseado em entrevistas com idosos atendidos de julho de 2014 a julho de 2015 em um centro de referência na Atenção à Saúde do Idoso de um hospital de ensino. Foram coletadas informações clínicas, demográficas e farmacoterápicas. Resultados Entrevistaram-se 170 idosos, 85,9% eram mulheres e a mediana de idade foi 76 anos. A frequência de automedicação foi 80,5%. Os medicamentos mais utilizados por automedicação foram relaxantes musculares de ação central, analgésicos e antipiréticos, além dos anti-inflamatórios e antireumáticos não esteroidais. Entre os idosos que praticaram automedicação, 55,5% utilizaram medicamentos inapropriados para idosos, segundo os critérios de Beers de 2015, e 56,9% utilizam medicamentos que apresentavam duplicidade terapêutica com os medicamentos prescritos. Foram identificados 57 medicamentos utilizados por automedicação, e 30 (52,6%) eram classificados como isentos de prescrição e 27 (47,4%) como de venda sob prescrição médica. Cerca de 68,6% dos idosos apresentavam pelo menos uma interação envolvendo medicamentos prescritos e utilizados por automedicação. Conclusão A prática de automedicação foi elevada nos idosos estudados. O amplo uso de medicamentos de venda livre e/ou potencialmente inapropriados para idosos aumenta o risco de interações medicamentosas e de eventos adversos.

Effects of Medication Reconciliation and Cost Avoidance Analysis by Clinical Pharmacists in a Neurocritical Care Unit

BACKGROUND: The role of clinical pharmacists in medication therapy to improve clinical and economic outcomes has been reported in the literature. This study was conducted to analyze the changes in details of medication interventions before and after the introduction of clinical pharmacists into the care of neurocritical care unit (NCU) patients, and to evaluate the economic effects of clinical pharmacists by calculating the avoidance cost. METHODS: A retrospective study was conducted reviewing the electronic medical records from June 2013 to May 2014 (before), and from June 2016 to May 2017 (after). We calculated the number and rates of intervention, the acceptance rates of it, and also reviewed the list of interventions. We calculated avoidance cost if there was no intervention. RESULTS: The monthly mean number of interventions increased from 8.0 (±5.7) to 31.7 (±12.8) (P < 0.001) and the frequency of intervention also increased from 0.8% to 1.6% (P=0.003). The most frequently provided pharmacist intervention was nutritional support before introduction of clinical pharmacists and discussions on the medication plan after. The number of classified interventions was 14 before introduction of clinical pharmacist services and 33 after. The calculated cost avoidance associated with a clinical pharmacists' integration was 77,990,615 won per year. CONCLUSION: Introduction of clinicals pharmacist into the NCU was associated with increased intervention rates and expanded types of clinical interventions. The cost avoidance achieved by the pharmacists' interventions can be further explored to evaluate if similar expansions of pharmacists' services achieve similar results in other settings.

Identificação de reações adversas a medicamentos (ram) durante conciliação medicamentosa em hospital escola / Identificación de reacciones adversas a medicamentos (ram) durante conciliación medicación en un hospital universitario / Identification of adverse drug reactions (adr) for medication conciliation in a teaching hospital

RESUMO As Reações Adversas a Medicamentos (RAM) representam um grande problema nos hospitais, acarretando sérios riscos à saúde dos pacientes e aumentando os custos da atenção à saúde. O presente estudo teve o objetivo de analisar as principais Reações Adversas a Medicamentos encontradas no setor de Clínica Médica de um hospital escola em Campos dos Goytacazes - RJ. Realizou-se um estudo longitudinal prospectivo entre os meses de março a junho de 2015. Um total de 194 pacientes foram acompanhados, sendo observado reações adversas em 37 deles, totalizando 40 reações adversas que envolveram 27 princípios ativos. Os principais medicamentos envolvidos nas RAM foram losartana (12,5%), dipirona (10%) e tramadol (7,5%). As reações acometeram principalmente pacientes do sexo masculino (60%). Quanto à causalidade, 12 (30%) RAM foram classificadas como definidas, 19 (47,5%) prováveis e 9 (22,5%) possíveis, pelo algoritmo de Naranjo. Trinta e cinco RAM (87,5%) foram classificadas como reações do tipo A (previsíveis) e apenas 5 (12,5%) reações do tipo B (imprevisíveis). A Comissão de Farmacovigilância do Hospital foi comunicada para proceder as notificações à ANVISA. O processo de conciliação de medicamentos contribuiu para a identificação de RAM, permitindo ao profissional farmacêutico atuação mais efetiva junto à equipe multiprofissional de saúde no que se refere às reações indesejáveis causadas pelos medicamentos possibilitando a prevenção de agravos relacionados à terapia medicamentosa e ações voltadas para a segurança dos pacientes.

RESUMEN Las Reacciones Adversas a Medicamentos (RAM) representan un gran problema en los hospitales, causando serios riesgos a la salud de los pacientes y aumentando los costos de atención a la salud. En este contexto, este estudio tuvo como objetivo analizar las principales Reacciones Adversas a Medicamentos encontradas en el sector de Clínica Médica de un hospital universitario en Campos dos Goytacazes-Rio de Janeiro-Brasil. Se realizó un estudio longitudinal prospectivo entre los meses de marzo a junio de 2015. Un total de 194 pacientes fueron acompañados y fueron observadas reacciones adversas en 37 pacientes, totalizando 40 reacciones adversas que involucraron 27 principios activos. Los principales medicamentos involucrados en las RAM fueron losartán (12,5%), dipirona (10%) y tramadol (7,5%). Las reacciones acometieron principalmente pacientes del sexo masculino (60%). En cuanto a la causalidad, 12 (30%) RAM fueron clasificadas como definidas, 19 (47,5%) probables y 9 (22,5%) posibles, por el algoritmo de Naranjo. Treinta y cinco RAM (87,5%) fueron clasificadas como reacciones del tipo A (previsibles) y solo 5 (12,5%) reacciones del tipo B (imprevisibles). El Comité de Farmacovigilancia Hospitalaria fue comunicado para emprender las notificaciones a la ANVISA. El proceso de conciliación de medicamentos contribuyó a la identificación de RAM, permitiendo al profesional farmacéutico una actuación más eficaz junto al equipo multidisciplinario de salud en lo que se refiere a las reacciones indeseables causadas por los medicamentos, posibilitando la prevención de agravios relacionados a la terapia medicamentosa y acciones dirigidas a la seguridad del paciente.

ABSTRACT Currently, Adverse Drug Rreactions (ADR/RAM) are a major problem in hospitals, causing serious health risks for patients and increasing costs of health care. In this context, this study aimed to analyze the main adverse drug reactions found in medical clinic sector a teaching hospital in Campos dos Goytacazes - RJ. We conducted a prospective study between the months from March to June 2015. A total of 194 patients were followed, adverse reactions were observed in 37 patients, involving 40 adverse reactions distributed in 27 active ingredients. The major drugs were involved in the ADR (12.5%) of losartan, 4 (10%) of dipyrone and 3 (7.5%) tramadol. The reactions of most patients were in males with 63%. As for the causality, 12 ADR (30%) were classified as definite, 19 (47.5%) probable and 9 (22.5%) possible, by the logotype of Naranjo. Thirty-five ADRs (87%) were defined as the type A (predictable) and only 5 (12.5%) type B reactions. The Pharmacovigilance Committee of the Hospital was reported to make notifications to ANVISA. The medication reconciliation process contributed to the identification of RAM, allowing the professional pharmacist for more effective action by the multidisciplinary health team in regard to undesirable reactions caused by drugs enabling the prevention of related harm to drug therapy and targeted actions to patient safety.

Conciliación farmacoterapéutica en las áreas de transición en la atención del paciente en un hospital pediátrico de alta complejidad / Medication reconciliation at areas of transition in the patient care at a tertiary pediatric hospital

Introducción: La Conciliación Farmacoterapéutica garantiza el tratamiento medicamentoso correcto (dosis, vía y frecuencia) en relación a la situación actual del paciente. Objetivos: Determinar el grado de seguridad farmacoterapéutica en todas las transiciones del cuidado del paciente. Métodos: estudio descriptivo, transversal. Se realizó conciliación en las primeras 24 hs del ingreso en CIM (salas de internación de cuidados intermedios o moderados), Emergencia o UCI. Se incluyeron pacientes crónicos, que recibían más de 4 medicamentos, con readmisiones frecuentes y/o fármacos de bajo índice terapéutico. Se entrevistó a los pacientes/cuidadores, con previa firma del consentimiento informado y se recolectaron datos de la HCE para comparar el "mejor listado de medicación" obtenido con la indicación médica actual para analizar las discrepancias encontradas y resolverlas. Resultados: Se conciliaron en total 320 pacientes, encontrándose 1343 discrepancias totales, de las cuales 220 (16%) fueron errores de medicación. Se conciliaron 105 pacientes en la etapa emergencia (donde hubo más errores) 101 en la etapa CIM y 92 en la etapa UCI. El 42% de los pacientes sufrió al menos 1 error de medicación (omisión de indicación, el más frecuente). La mayoría de los errores no llegaron al paciente, esto fue evitado en el 52% por el padre y en el 39% por el farmacéutico. El 7% de los errores que llegaron al paciente causaron daños. En la conciliación al alta se halló que no se asienta en la HC la farmacoterapia de base. Conclusiones: La magnitud de los errores hallados es considerable, por lo que debería implementarse en forma rutinaria un programa de conciliación terapéutica, con énfasis en Emergencia (AU)

Introduction: Medication reconciliation guarantees adequate drug treatment (dose, route, and frequency) according to the current state of the patient. Aims: To determine the degree of medication safety in all transitions of patient care. Methods: A descriptive cross-sectional study. Reconciliation was carried out in the first 24 hours after admission to the ward (intermediate or moderate care wards), emergency department, or ICU. Chronic patients receiving more than 4 different drugs, with frequent readmissions, and/or narrow therapeutic index medications were included. Patients/caregivers were interviewed after signing informed consent and data were collected from the medical chart to compare the "best list of medications" obtained with the current medical indications to analyze discrepancies and resolve them. Results: Overall, reconciliation was carried out in 320 patients and 1343 discrepancies were observed, of which 220 (16%) were found to be medication errors. Reconciliation was carried out in 105 patients at the emergency department (where most errors were made), in 101 on the wards, and in 92 in the ICU. In 42% of the patients at least one medication error was observed (being omission of the indication the most common). The majority of errors did not affect the patient; they were avoided by the parent in 52% and by the pharmacist in 39%. Seven percent of the errors that did affect the patient caused damage. At reconciliation at discharge we found that in the medical chart baseline pharmacotherapy was not recorded. Conclusions: The magnitude of errors found was considerable and therefore a program of medication reconciliation should be routinely implemented, with emphasis on the emergency department (AU)

Analysis of the discrepancies identified during medication reconciliation on patient admission in cardiology units: a descriptive study / Análise das discrepâncias encontradas durante a conciliação medicamentosa na admissão de pacientes em unidades de cardiologia: um estudo descritivo / Análisis de las discrepancias encontradas durante la conciliación medicamentosa en la admisión de pacientes en unidades de cardiología: un estudio descriptivo

ABSTRACT Objectives: this observational study aimed to describe the discrepancies identified during medication reconciliation on patient admission to cardiology units in a large hospital. Methods: the medication history of patients was collected within 48 hours after admission, and intentional and unintentional discrepancies were classified as omission, duplication, dose, frequency, timing, and route of drug administration. Results: most of the patients evaluated were women (58.0%) with a mean age of 59 years, and 75.5% of the patients had a Charlson comorbidity index score between 1 and 3. Of the 117 discrepancies found, 50.4% were unintentional. Of these, 61.0% involved omission, 18.6% involved dosage, 18.6% involved timing, and 1.7% involved the route of drug administration. Conclusion: this study revealed a high prevalence of discrepancies, most of which were related to omissions, and 50% were unintentional. These results reveal the number of drugs that are not reincorporated into the treatment of patients, which can have important clinical consequences.

RESUMO Objetivos: este estudo observacional teve como objetivo descrever discrepâncias encontradas na realização de conciliação medicamentosa de pacientes admitidos em unidades de cardiologia de um hospital de grande porte. Métodos: a história de medicação dos pacientes foi coletada dentro de 48h após a admissão, e as discrepâncias, identificadas como intencionais ou não intencionais, foram classificadas como de: omissão, duplicidade, dose, frequência, intervalo e via. Resultados: a maioria dos pacientes incluídos pertençia ao sexo feminino (58,0%), com idade média de 59 anos, e com índice de comorbidades de Charlson entre 1 e 3 (75,5% dos casos). Das 117 discrepâncias encontradas, 50,4% foram não intencionais. Dessas, 61,0% foram de omissão, 18,6% de dose, 18,6% de intervalo e 1,7% de via de administração. Conclusão: o estudo mostra a alta prevalência de discrepâncias, principalmente de omissão, sendo quase metade não intencionais. Esse dado remete ao número de medicamentos que não são reincorporados ao tratamento dos pacientes, podendo repercutir em consequências clínicas importantes.

RESUMEN Objetivos: este estudio observacional tuvo como objetivo describir discrepancias encontradas en la realización de la conciliación medicamentosa de pacientes admitidos en unidades de cardiología de un hospital de gran porte. Métodos: la historia de medicación de los pacientes fue recolectada dentro de 48h después de la admisión, y las discrepancias, identificadas como intencionales o no intencionales, fueron clasificadas como: omisión, duplicidad, dosis, frecuencia, intervalo y vía. Resultados: la mayoría de los pacientes incluidos pertenecía al sexo femenino (58,0%), con edad promedio de 59 años, y con índice de comorbilidad de Charlson entre 1 y 3 (75,5% de los casos). De las 117 discrepancias encontradas, 50,4% fueron no intencionales. De estas, 61,0% fueron de omisión, 18,6% de dosis, 18,6% de intervalo y 1,7% de vía de administración. Conclusión: el estudio muestra la alta prevalencia de discrepancias, principalmente de omisión, siendo casi mitad de ellas no intencionales. Ese dato nos indica el número de medicamentos que no son reincorporados al tratamiento de los pacientes, lo que puede repercutir en consecuencias clínicas importantes.

Medication reconciliation as a strategy for preventing medication errors

ABSTRACT One of the current barriers proposed to avoid possible medication errors, and consequently harm to patients, is the medication reconciliation, a process in which drugs used by patients prior to hospitalization can be compared with those prescribed in the hospital. This study describes the results of a pharmacist based reconciliation conducted during six months in clinical units of a university hospital. Fourteen patients (23.33%) had some kind of problem related to medicine. The majority (80%) of medication errors were due to medication omission. Pharmaceutical interventions acceptance level was 90%. The results suggest that pharmacists based reconciliation can have a relevant role in preventing medication errors and adverse events. Moreover, the detailed interview, conducted by the pharmacist, is able to rescue important information regarding the use of drugs, allowing to avoid medications errors and patient injury.

RESUMO Uma das barreiras propostas para se evitar possíveis erros relacionados a medicamentos e, consequentemente, que danos acometam o paciente, é a reconciliação medicamentosa no ato da internação, processo no qual se comparam os medicamentos usados pelos pacientes previamente à internação com os prescritos no âmbito hospitalar. Este trabalho descreve os resultados de seis meses de um processo de reconciliação conduzido por farmacêutico em unidades clínicas de um hospital universitário. Quatorze pacientes (23.33%) tiveram algum tipo de problema relacionado ao uso de medicamentos. A maioria dos erros envolvendo medicamentos (80%) estava relacionada à omissão de medicamentos. As intervenções farmacêuticas tiveram 90% de aceitação pelos médicos. Os resultados sugerem que a atuação de farmacêuticos na reconciliação medicamentosa pode desempenhar papel relevante na prevenção de erros de medicamentos e eventos adversos. Além disso, a entrevista detalhada conduzida por um farmacêutico se mostrou capaz de resgatar informações importantes sobre o uso dos medicamentos, permitindo evitar erros e danos ao paciente.

A Systematic Review on the Vocational Pharmacy Education and Pharmacists' Role in the Singapore's Healthcare System

BACKGROUND: Singapore has the stable healthcare system with utilizing pharmacist manpower in proper positions by demand of populations' health among Asian countries. OBJECTIVE: This study aims to systematically review (1) the pharmacists' role and (2) the pharmacy education system of Singapore in comparison with Korea. METHOD: We searched for information about academic, medical and governmental institutions related to professional pharmacists' practice in Singapore by primarily using database such as DBpia, KISS, Google Scholar and ProQuest and the official website of the Singapore Ministry of Health. We contacted and arranged the visit schedules with National University of Singapore, National Health Group's polyclinics, Agency for Integrated Care, National University Hospital, and community chain pharmacies. During onsite visits, we interviewed pharmacists working in each institution and obtained additional documents and materials relevant to this manuscript work. RESULTS: To become a registered pharmacist in Singapore, the pharmacy curriculum requires four full-time academic years and six additional months allotted for pre-registration training. Pharm.D. course is offered for pharmacy graduate students with additional two full-time years of study. Team teaching and inter professional education program seem the most significant method in pharmacy education. Pharmacists working at hospitals, polyclinics, and community pharmacies in Singapore take broader roles and offer more cognitive services such as smoking cessation program and medication reconciliation. Especially, pharmacists in Agency for Integrated Care fill the role of primary care providers for the continuing care of the community through the governmental support toward the patients-centered integrated care. CONCLUSION: Singaporean pharmacists take significant and active roles in collaboration with other healthcare providers. Efforts such as interprofessional pharmacy education and governmental endorsement of the systematic and interactive care between pharmacists and other medical providers in Singapore are needed to be urgently applied to Korea healthcare system for the promotion of population health.

Challenges in Patient Counseling and Medication Reconciliation for Foreign Inpatients in Korea

OBJECTIVE: This study is to evaluate the awareness, needs, and barriers in patient counseling for hospitalized foreign patients. As the number of foreign population increases in Korea, demands on quality of Korean health services are rapidly increasing. Previously most of the studies have focused on the availability and utilization of healthcare service, and prevalence of disease for foreigners, however, no study has been conducted on quality of direct-patient care such as patient counseling. METHOD: In the present study, a survey was conducted on a total of 161 participants between March 7 and May 7 in 2014. The study subjects were consisted with 103 foreign patients who had experienced inpatient care within 1 year and 58 hospital pharmacists who work in the hospital with foreign inpatients. RESULTS: Firstly, the hospital pharmacists were highly aware of the necessity of counseling for foreign inpatients. Secondly, the largest portion of barrier to patient counseling service was accounted a lack of foreign language skills. Lastly, the monitoring of efficacy, potential adverse reactions and discharge follow-up were emphasized. CONCLUSION: Effective communication skills would be essential to improve pharmaceutical care services to foreign inpatients.

Medication discrepancies and associated risk factors identified among elderly patients discharged from a tertiary hospital in Singapore

<p><b>INTRODUCTION</b>Medication discrepancies and poor documentation of medication changes (e.g. lack of justification for medication change) in physician discharge summaries can lead to preventable medication errors and adverse outcomes. This study aimed to identify and characterise discrepancies between preadmission and discharge medication lists, to identify associated risk factors, and in cases of intentional medication discrepancies, to determine the adequacy of the physician discharge summaries in documenting reasons for the changes.</p><p><b>METHODS</b>A retrospective clinical record review of 150 consecutive elderly patients was done to estimate the number of medication discrepancies between preadmission and discharge medication lists. The two lists were compared for discrepancies (addition, omission or duplication of medications, and/or a change in dosage, frequency or formulation of medication). The patients' clinical records and physician discharge summaries were reviewed to determine whether the discrepancies found were intentional or unintentional. Physician discharge summaries were reviewed to determine if the physicians endorsed and documented reasons for all intentional medication changes.</p><p><b>RESULTS</b>A total of 279 medication discrepancies were identified, of which 42 were unintentional medication discrepancies (35 were related to omission/addition of a medication and seven were related to a change in medication dosage/frequency) and 237 were documented intentional discrepancies. Omission of the baseline medication was the most common unintentional discrepancy. No reasons were provided in the physician discharge summaries for 54 (22.8%) of the intentional discrepancies.</p><p><b>CONCLUSION</b>Unintentional medication discrepancies are a common occurrence at hospital discharge. Physician discharge summaries often do not have adequate information on the reasons for medication changes.</p>

Avaliação do processo de conciliação medicamentosa em pacientes pediátricos em um hospital público especializado no estado do Rio de Janeiro / Evaluation of the drug reconciliation process in pediatric patients in a specialized public hospital in the state of Rio de Janeiro

Poucos estudos avaliaram a frequência de erros cometidos pelos profissionais de saúde em pacientes pediátrica em comparação com estudos em adultos. A conciliação medicamentosa é considerada uma solução para prevenir erros de medicação no cuidado do paciente. O objetivo deste estudo foi avaliar o processo de conciliação medicamentosa na admissão hospitalar e na transferência interna de pacientes pediátricos em um hospital público especializado no Rio de Janeiro. Foi realizado um estudo observacional prospectivo, com busca ativa de discrepâncias medicamentos as utilizando diferentes fontes de dados. Foram identificadas 137 discrepâncias na admissão hospitalar com 210 medicamentos em 38 (92,7 por cento) dos 41 participantes do estudo, das quais 39 (28,5 por cento) foram discrepâncias não intencionais, dentre as quais 25(64,1 por cento) foram erros por omissão. Na transferência interna foram identificadas 31discrepâncias com 69 medicamentos em sete (87,5 por cento) dos oito participantes, das quais17 (54,8 por cento) foram discrepâncias não intencionais e destas a maior parte 6 (35,5 por cento) foram de erro por omissão. A quantidade de medicamentos em uso pelo paciente foi um fator de risco para a ocorrência discrepâncias no momento da admissão hospitalar, com risco relativo (RR) de 1,27 (intervalo de confiança 95 por cento, (...). O processo proposto e os instrumentos adaptados para contexto de hospitais brasileiros podem ser utilizados em outros serviços...

Few studies have evaluated the frequency of errors made by health professionals in thepediatric patients compared to studies in adults. Medication reconciliation is considereda solution to prevent medication errors in patient care. The objective of this study was toevaluate the medication reconciliation process at admission and internal transfer ofpediatric patients in a specialized public hospital in Rio de Janeiro. A prospective observational study, with active search for medication discrepancies using different datasources was conducted. We identified 137 discrepancies in the admission of 210 drugsin 38 (92.7 percent) of the 41 study participants, of which 39 (28.5 percent) were unintentional discrepancies, among which 25 (64.1 percent) were error by omission. In internal transferwere identified 31 discrepancies with 69 drugs in seven (87.5 percent) of the eightparticipants, of which 17 (54.8 percent) were unintentional discrepancies and these most 6(35.5 percent) were error by omission. The amount of drugs taken by the patient was a riskfactor to the occurrence discrepancies at hospital admission, with relative risk (RR) of1.27 (95 percent confidence interval, (...). The proposed process and adapted instruments for Brazilian hospitals may be used in other services. The forms of medication reconciliation when available in medical charge provide information about drugs for everyone involved in patient care. Pharmacists working in medication conciliation identify and help provides more discrepancies and medication errors and provide evidence for the medical staff which help increase patient safety. Medication reconciliation of patients with more drugs should be prioritized in services with few human resources...

Segurança do paciente no uso de medicamentos após a alta hospitalar: estudo exploratório1 / Patient safety and medication use after discharge: exploratory study1

No Brasil, são escassos os estudos sobre estratégias para a segurança do paciente no processo de uso de medicamentos após a alta hospitalar, o que dificulta o conhecimento sobre a atuação de hospitais brasileiros nessa área. Neste artigo, buscou-se compreender a dinâmica e os desafios do cuidado fornecido ao paciente pela equipe hospitalar, visando à segurança no processo de uso de medicamentos após a alta hospitalar. Realizou-se pesquisa exploratória por meio de entrevistas com médicos, enfermeiros, farmacêuticos e assistentes sociais do Hospital Universitário da Universidade de São Paulo. Foram pesquisadas as atividades de cuidado com a farmacoterapia durante e após a hospitalização, incluindo o acesso a medicamentos após alta, a existência de articulação do hospital com outros serviços de saúde, e barreiras para desenvolver essas atividades. A principal estratégia adotada é a orientação de alta, realizada de forma estruturada, principalmente para cuidadores de pacientes pediátricos. Em situações específicas, ocorre mobilização da equipe para viabilização do acesso a medicamentos prescritos na alta. Reconciliação medicamentosa está em fase de implantação, e visita domiciliar é realizada apenas para pacientes críticos com problemas de locomoção. As principais barreiras identificadas foram insuficiência de recursos humanos e falta de tecnologias de informação. Conclui-se que são desenvolvidas algumas estratégias, porém com limitações e sem articulação adequada com outros serviços de saúde para a continuidade do cuidado. Isto sugere a necessidade de concentração de esforços para transpor as barreiras identificadas, contribuindo para a segurança do paciente na interface entre hospital, atenção básica e domicílio...

Few Brazilian studies have focused on patient safety strategies for safe use of medications after discharge leading to limited knowledge of current safety practices developed in Brazilian hospitals. The present study aimed to understand the dynamics and challenges of care provided to patients by hospital providers focusing on safe use of medications after discharge. An exploratory study was conducted and data was collected through interviews with physicians, nurses, pharmacists and social workers at the Hospital Universitário da Universidade de São Paulo, in São Paulo, southeastern Brazil. Care practices regarding medication use during and following hospital stay including access to medicines after discharge, follow-up plans for coordinated, ongoing care, and barriers were investigated. The main strategy for safe use of medications after hospital discharge is to provide structured counseling for patients and particularly for caregivers of pediatric patients. The care team works to ensure access to the medications prescribed at discharge in special situations. Medication reconciliation is being implemented and home visits are limited to patients in critical condition with mobility problems. The main barriers identified in the study were limited information technology and human resources. It was concluded that there are some patient safety strategies in place but they are limited in scope and do not ensure coordinated, ongoing care after discharge. These findings point to a need to strengthen efforts to overcome the barriers identified to improve patient safety at the interface of hospital, primary care and the home setting...