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.