Main measures
The data were collected from April to August 2017. Before data
collection, two study coordinators (L.M.C.S. and C.C.S.) trained a team
of research assistants (A.S.D., G.A.C.C., L.A.M., R.O.S.S. and T.S.A.)
to properly apply the data collection form and clarified their
questions. The research assistants were pharmacists and researchers,
members of the same research group. All medical records were assessed by
the team. Cases of divergence regarding the communication failure were
resolved by consensus among them.
All data were manually reported in paper medical records which contained
all medications prescribed during the hospitalization. The clinical
notes made by pharmacists, physicians and nurses, and healthcare
professionals involved in the use of medications, were examined at three
transition points of care (hospital admission, during the hospital stay,
and hospital discharge).
At hospital admission, data were collected from admission forms or, when
they were not present, from the first medical note in the patient
medical record. Pharmacists and nurses’ notes from the first day of
hospitalization were also considered as sources of information for
hospital admission as well the physician’s notes. We considered
admission as the first day of hospitalization, and hospital stay from
the following days. During the hospital stay, data were extracted from
medications prescriptions, pre-anesthetic evaluations, forms requesting
other expert opinions and the pharmacists’, physicians’, and nurses’
notes. At hospital discharge, only information presented in the hospital
discharge form was evaluated or, when it was not present, the last
registered clinical note of a pharmacist, physician, or nurse was
considered.