Hospital stay
Regarding the prescribed medications during hospitalization, 1,588
changes were identified, with an average of 9.45 (I.C. 95%; 7.71 to
11.19) changes per patient. Only 390 (24.5%) of such changes were
justified. Of the justified changes, most were the addition of
medications (n=199, 51.0%), followed by treatment suspension (n=84,
21.5%) and adjustments in dose (n=50, 12.8%). Furthermore, 29
justified changes related to recommendations made by physicians, two
related to nurses, and one related to pharmacists. The recommendations
of these professionals were accepted in all 32 cases.
In 48 (23.7%) of the 202 medical records, there were 116
non-conformities related to medications in the nurses’ clinical notes.
In addition, 59 direct references to other professionals were observed.
The physicians were the most mentioned (n=39, 66.1%), followed by
nurses (n=19, 32.2%) and nutritionists (n=1, 1.7%). From the
references described, 26 (44.0%) indicated interventions in the
patients’ pharmacotherapy. Among the actions suggested, the suspension
of medication administration, given the patients’ clinical condition and
changes in administration time by physician orders, were observed.
Only 11 (5.4%) medical records contained a pharmacist report of
non-conformities related to the use of medications. Seventeen
non-conformities were identified, of which four (25.0%) related to the
risk of drug interactions, three (18.7%) to the identification of
medication discrepancies and two (12.5%) to allergic reactions after
medication administration. In addition, the pharmacist documented the
conduct performed to solve eight (50%) of these non-conformities.
Reference to the physician was found in three cases.