Resumo:
ABSTRACT
MEDICATION RECONCILIATION IN PATIENTS OF A UNIVERSITY HOSPITAL
Introduction: Medication reconciliation is among the strategies to improve patient
safety, since it ensures the necessary prescribed drugs during the care transition
processes. An accurate medical history in medical records is important when patients
are admitted to hospitals, since this record can prevent failures such as discontinuing
medications required by patients. Objective: to evaluate the effectiveness of
medication reconciliation in the identification of medication errors on admission of
patients at a university hospital and whether medication records are duly completed
in the medical records of these reconciled patients. Methods: A reconciled list was
created among the prescribed drugs on admission and those used on hospital preadmission;
then, records of the reconciled patients were evaluated with a view to
identifying records of the patients' usual medicines performed on admission and
discharge from hospital. Data were analyzed through descriptive statistics. Results:
107 patients were included and 226 discrepancies were found in 92 patients; of
these, 46 (21.4%) were unintended in 34 (31.8%) patients. Among the unintended
discrepancies, the omission of medication had the highest occurrence (65.2%) and
twenty-seven drugs were involved with unintended discrepancies, of which 13
(48.1%) are considered potentially dangerous drugs. Of the 107 patients, 102 had
their admission records and discharge summaries evaluated. Seventy-five (73.5%)
had medical admission records with pre-admission medications and only 51 (50%)
had discharge records. No single admission record was considered complete. When
evaluating whether information about drugs prescribed on admission was complete,
we observed that, of the 373 drugs, 301 had a recorded dose. Only 11 discharge
summaries had complete drug registration records with all items. Conclusion: The
medication reconciliation was effective in detecting medication errors, since a large
number of unintentional discrepancies were identified. Failures in drug registration
have been identified which may be related to the unintended discrepancy rates
detected. These failures may hinder the drug reconciliation process.
Keywords: Medication reconciliation. Medication errors. Discharge summary.
Record. Care transition.
