No Brasil, o câncer atualmente é a segunda causa de morte e algumas das explicações devem-se ao fato do melhor controle das doenças infectocontagiosas e ao envelhecimento populacional global, uma vez que o câncer é considerado uma doença cuja idade média está acima de 60 anos. As comorbidades as quais estão diretamente associadas ao envelhecimento e o uso de diversos medicamentos são necessários para o controle adequado das outras patologias, por outro lado, representa um importante fator de risco para resultados negativos de saúde. A conciliação de medicamentos visa a redução de medicamentos desnecessários, com uma avaliação criteriosa do farmacêutico, que pode ajudar a otimizar a terapia medicamentosa, reduzir custos, aumentar a conformidade e reduzir a toxicidade e eventos adversos relacionados aos medicamentos. OBJETIVO: Avaliar a prevalência da polifarmácia, automedicação, a adesão e conhecimento da farmacoterapia domiciliar; as principais dúvidas e as necessidades de orientação em relação à farmacoterapia em geral; harmonização farmacoterapêutica, discrepâncias, interações medicamentosas, medicamentos inapropriados para idosos e duplicidade terapêutica. CASUÍSTICA E MÉTODOS: Pacientes admitidos dos pelo Serviço de Oncologia Clínica e Ginecologia do HCFMRPUSP com idade igual ou superior a 60 anos e diagnóstico confirmado de neoplasia maligna. Foram aplicados os testes de adesão e conhecimento da farmacoterapia domiciliar e após a saída hospitalar do paciente realizada a revisão das farmacoterapias (domiciliar e hospitalar) e a conciliação de medicamentos. RESULTADOS: Foram incluídos 157 pacientes, idade média 68,4 anos, maioria do gênero feminino (60,5%), raça branca (84,1%), ensino básico (40,1%), neoplasia maligna em mama feminina (26,1%), em uso de polifarmácia (70,7%) e adepto de automedicação (50,3%), em que o uso de medicamentos (p= 0,01) e a automedicação (p= <0,01) foram significativamente correlacionados com o gênero feminino. Na farmacoterapia domiciliar, a média de conhecimento total foi de 62,9% e maioria caracterizada como não aderente (73,4%), o armazenamento dos medicamentos foi prevalente na cozinha (51%) e as principais dúvidas relacionam-se à caligrafia (79%). A harmonização farmacoterapêutica foi observada em 82,3% dos pacientes. A discrepância foi observada em 90,5% dos pacientes, prevalecendo a omissão (304). Foi significativamente diferente a interação medicamentosa quando comparada as farmacoterapias, domiciliar e hospitalar (p <0,01). Em ambas farmacoterapias, a maioria dos pacientes fez uso de medicamentos inapropriados para idosos, 84,1% (132 pacientes) e 85,3% (134 pacientes), respectivamente. A duplicidade terapêutica observada foi mínima, 18 pacientes (11,7%) na farmacoterapia domiciliar e 29 pacientes (18,8%) na hospitalar. CONCLUSÃO: a inserção do cuidado farmacêutico pode contribuir na educação do paciente em relação aos riscos da automedicação, melhoria no conhecimento, adesão e armazenamento dos medicamentos; e o processo de conciliação de medicamentos pode auxiliar a prática clínica na harmonização farmacoterapêutica e reduzir as discrepâncias, principalmente em relação à omissão. A inclusão de sistemas de alertas na prescrição médica pode reduzir os riscos de interações medicamentosas e uso de medicamentos inapropriados para idosos. / In Brazil, cancer is currently the second cause of death and some of the explanation is due to better control of infectious diseases and global aging, since cancer is considered a disease whose average age is over 60 years. Comorbidities that are directly associated with aging and the use of several medications are necessary for the adequate control of other pathologies, on the other hand, it represents an important risk factor for negative health outcomes. Medication reconciliation is aimed at reducing unnecessary medications, with careful evaluation by the pharmacist, which can help optimize drug therapy, reduce costs, increase compliance, and reduce toxicity and drug-related adverse events. OBJECTIVE: To evaluate the prevalence of polypharmacy, self-medication, adherence and knowledge of home pharmacotherapy; the main doubts and orientation needs regarding pharmacotherapy in general; pharmacotherapeutic harmonization, discrepancies, drug interactions, inappropriate medications for the elderly and therapeutic duplicity. MATERIALS AND METHODS: Patients admitted to the HCFMRP-USP Clinical Oncology and Gynecology Service aged 60 years or older and confirmed diagnosis of malignant neoplasia. The adherence tests and knowledge of home pharmacotherapy were applied and after the patient\'s hospital discharge, the pharmacotherapies (home and hospital) and medication reconciliation were reviewed. RESULTS: A total of 157 patients, mean age 68.4 years old, female (60.5%), Caucasian (84.1%), primary education (40.1%) and malignant neoplasia (P = 0.01) and self-medication (p = <0.01), using polypharmacy (70.7%) and adept of self-medication (50.3%), Were significantly correlated with the female gender. In home pharmacotherapy, the mean total knowledge was 62.9% and most characterized as non-adherent (73.4%), drug storage was prevalent in the kitchen (51%) and the main doubts related to calligraphy (79%). Pharmacotherapeutic harmonization was observed in 82.3% of the patients. The discrepancy was observed in 90.5% of the patients, with omission prevailing (304). Drug interaction was significantly different when compared to pharmacotherapies, home and hospital (p <0.01). In both pharmacotherapies, the majority of patients used drugs inappropriate for the elderly, 84.1% (132 patients) and 85.3% (134 patients), respectively. The therapeutic duplicity observed was minimal, 18 patients (11.7%) in the home pharmacotherapy and 29 patients (18.8%) in the hospital. CONCLUSION: the insertion of pharmaceutical care can contribute to the education of the patient in relation to the risks of self-medication, improved knowledge, adherence and storage of medications; and the medication reconciliation process can help clinical practice in pharmacotherapeutic harmonization and reduce discrepancies, especially in relation to omission. The inclusion of alert systems in the medical prescription can reduce the risks of drug interactions and the use of drugs inappropriate for the elderly.

No Brasil, o câncer atualmente é a segunda causa de morte e algumas das explicações devem-se ao fato do melhor controle das doenças infectocontagiosas e ao envelhecimento populacional global, uma vez que o câncer é considerado uma doença cuja idade média está acima de 60 anos. As comorbidades as quais estão diretamente associadas ao envelhecimento e o uso de diversos medicamentos são necessários para o controle adequado das outras patologias, por outro lado, representa um importante fator de risco para resultados negativos de saúde. A conciliação de medicamentos visa a redução de medicamentos desnecessários, com uma avaliação criteriosa do farmacêutico, que pode ajudar a otimizar a terapia medicamentosa, reduzir custos, aumentar a conformidade e reduzir a toxicidade e eventos adversos relacionados aos medicamentos. OBJETIVO: Avaliar a prevalência da polifarmácia, automedicação, a adesão e conhecimento da farmacoterapia domiciliar; as principais dúvidas e as necessidades de orientação em relação à farmacoterapia em geral; harmonização farmacoterapêutica, discrepâncias, interações medicamentosas, medicamentos inapropriados para idosos e duplicidade terapêutica. CASUÍSTICA E MÉTODOS: Pacientes admitidos dos pelo Serviço de Oncologia Clínica e Ginecologia do HCFMRPUSP com idade igual ou superior a 60 anos e diagnóstico confirmado de neoplasia maligna. Foram aplicados os testes de adesão e conhecimento da farmacoterapia domiciliar e após a saída hospitalar do paciente realizada a revisão das farmacoterapias (domiciliar e hospitalar) e a conciliação de medicamentos. RESULTADOS: Foram incluídos 157 pacientes, idade média 68,4 anos, maioria do gênero feminino (60,5%), raça branca (84,1%), ensino básico (40,1%), neoplasia maligna em mama feminina (26,1%), em uso de polifarmácia (70,7%) e adepto de automedicação (50,3%), em que o uso de medicamentos (p= 0,01) e a automedicação (p= <0,01) foram significativamente correlacionados com o gênero feminino. Na farmacoterapia domiciliar, a média de conhecimento total foi de 62,9% e maioria caracterizada como não aderente (73,4%), o armazenamento dos medicamentos foi prevalente na cozinha (51%) e as principais dúvidas relacionam-se à caligrafia (79%). A harmonização farmacoterapêutica foi observada em 82,3% dos pacientes. A discrepância foi observada em 90,5% dos pacientes, prevalecendo a omissão (304). Foi significativamente diferente a interação medicamentosa quando comparada as farmacoterapias, domiciliar e hospitalar (p <0,01). Em ambas farmacoterapias, a maioria dos pacientes fez uso de medicamentos inapropriados para idosos, 84,1% (132 pacientes) e 85,3% (134 pacientes), respectivamente. A duplicidade terapêutica observada foi mínima, 18 pacientes (11,7%) na farmacoterapia domiciliar e 29 pacientes (18,8%) na hospitalar. CONCLUSÃO: a inserção do cuidado farmacêutico pode contribuir na educação do paciente em relação aos riscos da automedicação, melhoria no conhecimento, adesão e armazenamento dos medicamentos; e o processo de conciliação de medicamentos pode auxiliar a prática clínica na harmonização farmacoterapêutica e reduzir as discrepâncias, principalmente em relação à omissão. A inclusão de sistemas de alertas na prescrição médica pode reduzir os riscos de interações medicamentosas e uso de medicamentos inapropriados para idosos. / In Brazil, cancer is currently the second cause of death and some of the explanation is due to better control of infectious diseases and global aging, since cancer is considered a disease whose average age is over 60 years. Comorbidities that are directly associated with aging and the use of several medications are necessary for the adequate control of other pathologies, on the other hand, it represents an important risk factor for negative health outcomes. Medication reconciliation is aimed at reducing unnecessary medications, with careful evaluation by the pharmacist, which can help optimize drug therapy, reduce costs, increase compliance, and reduce toxicity and drug-related adverse events. OBJECTIVE: To evaluate the prevalence of polypharmacy, self-medication, adherence and knowledge of home pharmacotherapy; the main doubts and orientation needs regarding pharmacotherapy in general; pharmacotherapeutic harmonization, discrepancies, drug interactions, inappropriate medications for the elderly and therapeutic duplicity. MATERIALS AND METHODS: Patients admitted to the HCFMRP-USP Clinical Oncology and Gynecology Service aged 60 years or older and confirmed diagnosis of malignant neoplasia. The adherence tests and knowledge of home pharmacotherapy were applied and after the patient\'s hospital discharge, the pharmacotherapies (home and hospital) and medication reconciliation were reviewed. RESULTS: A total of 157 patients, mean age 68.4 years old, female (60.5%), Caucasian (84.1%), primary education (40.1%) and malignant neoplasia (P = 0.01) and self-medication (p = <0.01), using polypharmacy (70.7%) and adept of self-medication (50.3%), Were significantly correlated with the female gender. In home pharmacotherapy, the mean total knowledge was 62.9% and most characterized as non-adherent (73.4%), drug storage was prevalent in the kitchen (51%) and the main doubts related to calligraphy (79%). Pharmacotherapeutic harmonization was observed in 82.3% of the patients. The discrepancy was observed in 90.5% of the patients, with omission prevailing (304). Drug interaction was significantly different when compared to pharmacotherapies, home and hospital (p <0.01). In both pharmacotherapies, the majority of patients used drugs inappropriate for the elderly, 84.1% (132 patients) and 85.3% (134 patients), respectively. The therapeutic duplicity observed was minimal, 18 patients (11.7%) in the home pharmacotherapy and 29 patients (18.8%) in the hospital. CONCLUSION: the insertion of pharmaceutical care can contribute to the education of the patient in relation to the risks of self-medication, improved knowledge, adherence and storage of medications; and the medication reconciliation process can help clinical practice in pharmacotherapeutic harmonization and reduce discrepancies, especially in relation to omission. The inclusion of alert systems in the medical prescription can reduce the risks of drug interactions and the use of drugs inappropriate for the elderly.

Falls are caused by many factors in older patients. Medications have been shown to be a risk factor for falls, and studies have shown that patients taking more than five total medications may have a two-fold increased risk of impaired balance. A more recent model suggests only medications with sedating and anticholinergic properties contribute significantly to physical impairment. The authors of this paper helped to develop a multidisciplinary clinic to evaluate the risk of falls in at-risk patients. We present the case of a woman on multiple medications that increased her risk of falling. Of note, this patient was taking a total of 14 prescription medications, seven of which were considered sedating. Based on a comprehensive medication evaluation, six specific changes were recommended to improve this patient's medication regimen and reduce her risk of falling.

Introduction: The objective of this study was to measure virtually-based objective structured clinical exam (OSCE) pass rates of student pharmacists who received remote, synchronous instruction on medication reconciliation compared with OSCE pass rates from the previous class, who received face to face synchronous instruction and OSCEs. The secondary objective was to measure student perceptions of remote instruction and OSCE preparation. Materials and Methods: Second year student pharmacists attended four online preparatory labs to learn and practice the process of performing a medication reconciliation. A virtually-based OSCE was used to assess student competency of identifying the primary or life-threatening medication related problem (MRP). Failing to identify the MRP represented a “kill point” and an automatic failing grade. A brief 10-item survey designed to measure student perceptions was sent to all participants post OSCE. Results: Seventy-seven students completed the OSCE and the overall pass rates were similar between the 2020 and 2019 class years (97% vs 94%, respectively; p = 0.24). Survey responses showed students lacked confidence, preferred face-to-face learning rather than online and most described their remote environments as not conducive to learning. Conclusion: Online instruction and assessment was at least as effective as traditional face-to-face methods. however the virtual-based platform was not preferred by learners.

Purpose: Healthcare organizations are mandated to improve quality and safety for patients while stressed with shorter lengths of stay, communication lapses between disciplines, and patient throughput issues that impede timely delivery of patient care. Nurses play a prominent role in the safe transition of patients from admission to discharge. Although nurses participate in discharge planning, limited research has addressed the role and outcomes of the registered nurse as a leader in the process. The aim of this study was determine if implementation of a nurse-driven discharge planning protocol for patients undergoing cardiac implant would result in improved organizational efficiencies, higher medication reconciliation rates, and higher patient satisfaction scores. Methods: A two-group posttest experimental design was used to conduct the study. Informed consent was obtained from 53 individuals scheduled for a cardiac implant procedure. Subjects were randomly assigned to either a nurse-driven discharge planning intervention group or a control group. Post procedure, 46 subjects met inclusion criteria with half (n=23) assigned to each group. All subjects received traditional discharge planning services. The morning after the cardiac implant procedure, a specially trained registered nurse assessed subjects in the intervention for discharge readiness. Subjects in the intervention groups were then discharged under protocol orders by the intervention nurse after targeted physical assessment, review of the post procedure chest radiograph, and examination of the cardiac implant device function. The intervention nurse also provided patient education, discharge instructions, and conducted medication reconciliation. The day after discharge the principal investigator conducted a scripted follow-up phone call to answer questions and monitor for post procedure complications. A Hospital Discharge Survey was administered during the subject's follow-up appointment. Results: The majority of subjects were men, Caucasian, insured, and educated at the high school level or higher. Their average age was 73.5+ 9.8 years. No significant differences between groups were noted for gender, type of insurance, education, or type of cardiac implant (chi-square); or age (t-test). A Mann-Whitney U test (one-tailed) found no significant difference in variable cost per case (p=.437) and actual charges (p=.403) between the intervention and control groups. Significant differences were found between groups for discharge satisfaction (p=.05) and the discharge perception of overall health (p=.02), with those in the intervention group reporting higher scores. Chi square analysis found no significant difference in 30-day readmission rates (p=.520). Using an independent samples t-test, those in the intervention group were discharged earlier (p=.000), had a lower length of stay (p=.005), and had higher rates of reconciled medications (p=.000). The odds of having all medications reconciled were significantly higher in the intervention group (odds ratio, 50.27; 95% CI, 5.62-450.2; p=.000). Discussion/Implications: This is the first study to evaluate the role of the nurse as a clinical leader in patient throughput, discharge planning, and patient safety initiatives. A nurse driven discharge planning protocol resulted in earlier discharge times which can have a dramatic impact on patient throughput. The nurse driven protocol significantly reduced the likelihood of unreconciled medications at discharge and significantly increased patient satisfaction. Follow-up research is needed to determine if a registered nurse can impact organizational efficiency and discharge safety in other patient populations.

Bakgrund: Antalet personer med multisjuklighet och polyfarmaci ökar i samhället. Läkemedelsrelaterade vårdskador och problem är vanligt förekommande i vården och polyfarmaci ökar risken. Läkemedelsgenomgångar är viktiga för att främja en säker läkemedelsanvändning och förebygga vårdskador. WHO beskriver läkemedelsgenomgångar som ett interprofessionellt teamarbete där ansvaret är delat mellan yrkesutövarna. Sjuksköterskor beskrivs kunna ha en egen och viktig roll i arbetet med läkemedelsgenomgångar. Syfte: Syftet med denna systematiska litteraturgranskning är att belysa sjuksköterskors erfarenheter av att utföra läkemedelsgenomgångar.  Metod: Studien är en systematisk litteraturgranskning och bygger på 16 kvalitativa vetenskapliga artiklar. Datainsamlingen genomfördes genom strukturerade databassökningar i Cinahl, Pubmed och Web of Science. Dataanalysen genomfördes enligt tematisk syntes av Thomas &amp; Harden. Tillförlitligheten av sammanvägningen bedömdes enligt CERQual. Resultat: Två tredje nivå teman utgör resultatet med underliggande andra nivå teman. Utmaningar och brister vid läkemedelsgenomgångar: resursbrister vid genomförande av läkemedelsgenomgångar, brist på kompetens hos sjuksköterskor vid genomförande av läkemedelsgenomgångar, utmaningar i det professionella samarbetet vid läkemedelsgenomgångar, utmaningar vid läkemedelsgenomgångar i vårdens övergångar, organisatoriska utmaningar och brister vid läkemedelsgenomgångar, bristande delaktighet och kunskap hos patienter vid läkemedelsgenomgångar. Underlättande faktorer vid läkemedelsgenomgångar: fördelar med samarbete vid läkemedelsgenomgångar samt fördelaktiga utfall och gynnsamma faktorer vid läkemedelsgenomgångar.   Konklusion: Förekomsten av utmaningar och fördelaktiga utfall vid läkemedelsgenomgångar bland sjuksköterskors erfarenheter belyser behovet av patientens delaktighet, kompetensutvecklingen hos sjuksköterskor och att utveckla riktlinjer och den organisatoriska strukturen kring arbetet med läkemedelsgenomgångar. Genom att studera sjuksköterskors bidragande roll vid läkemedelsgenomgångar kan sjuksköterskans roll i arbetet formaliseras. / Background: The number of people living with multimorbidity and polypharmacy increases in society. Drug-related health care misses and problems are common and the risk increases with polypharmacy. Medication reviews are important to facilitate safe drug use and to prevent medical errors. WHO describes medication reviews as a multiprofessional teamwork where response is shared between the professionals. Nurses are described to be able to have their own important role within the work of medication reviews.    Aim: The aim of this systematic literature review is to illustrate nurses experiences of performing medication reviews. Method: The study is a systematic literature review and is constructed of 16 qualitative scientific articles. Data collection was made through structured database searches in Cinahl, Pubmed and Web of Science. For the data analysis a thematic synthesis of Thomas and Harden was performed. To evaluate the confidence in the evidence CERQual was performed. Result: Two third level themes constitute the result with underlying second level themes. Barriers and deficits in medication reviews: resource shortages while performing medication reviews, lack of competence among nurses performing medication reviews, barriers within the interprofessional teamwork while performing medication reviews, barriers in medication reviews at care transitions, organizational barriers and deficits in medication reviews and lack of participation and knowledge in patintens while performing medication reviews. Facilitators in medication reviews: apportioning with teamwork in medication reviews and facilitating outcomes and factors of medication reviews.   Conclusion: The presence of challenges and beneficial outcomes in medication reviews among nurses' experiences highlights the need for patient involvement, the development of nurses' skills, and the development of guidelines and the organizational structure around the work of medication reviews. By studying the contributing role of nurses in medication reviews, the role of the nurse can be clarified and formalized.

CNPQ / The medication reconciliation process (RIM) have great impact in preventing adverse events and errors related to drugs and is a formal process of obtaining a complete and accurate listing of household medication that is compared to the hospital prescription list. The discrepancies found during this process can cause harm to patients. This becomes more serious when polymedicated patients, using three or more medications at home, undergo surgical procedure of urgency. OBJECTIVE. Evaluate occurrence of discrepancies in the pharmacotherapy of surgical patients at a hospital in the state of Sergipe. METHODOLOGY. This was an observational study of descriptive exploratory, cross-sectional study between August and November 2014, to assess the occurrence of discrepancies in the pharmacotherapy of patients admitted to the surgical hospital admission. Polymedicated patients were considered those who used three or more drugs. In the initial interview we consider as sources of information the patient himself, the companion, the domestic use of drugs led to hospitalization and consultation of the record. Discrepancies were classified as unintentional variation among the drugs used before admission and the prescribed medication list after surgery may be: failure of drugs, differences in dose, differences in the frequency / schedule of administration, duplicity therapy and interaction between medications. The data were tabulated and analyzed. RESULTS. No período do estudo 422 pacientes foram admitidos no internamento pós-cirúrgico. Desses, 80 (19%) atenderam ao critério de inclusão, composto por 43 (53,8%) mulheres e 37 (46,3%) homens, com média de idade 64,14 anos ± 17,0. O motivo de internação mais prevalente foi amputação de membro inferior ou superior 33 (41,3%); a média de medicamentos do domicílio foi 4,7 ± 1,9. Foi encontrado um total de 444 discrepâncias, com uma média por paciente de 5,5 ± 2,78, as mais prevalentes foram interação, que representou mais da metade de todas as discrepâncias identificadas, 53,4% (n=237) e a omissão que constituiu 25,7% (n=114). Foram realizadas 106 intervenções e apenas n=15 (14,2%) foram aceitas. CONCLUSION. Polymedicated patients undergoing surgery require special care since they are under the care of medical specialists focused on meeting the reason for his hospitalization. The study suggests that the discrepancies found may represent high risk for safety of these patients, a more effective process of identification of home therapy is necessary when the patient is subjected to hospitalization; some comorbidities are related to the large number of medications. Thus, actions to promote patient safety in hospital admission and reduce medication errors should be practiced. / O processo de reconciliação de medicamentos (RM) tem grande impacto na prevenção de eventos adversos e erros relacionados a medicamentos e consiste num processo formal de obtenção de uma lista completa e precisa dos medicamentos do domicílio que é comparada com a lista de prescrição hospitalar. As discrepâncias encontradas durante esse processo podem causar danos aos pacientes. Isso se torna mais grave quando pacientes polimedicados, em uso de três ou mais medicamentos no domicílio, são submetidos a procedimento cirúrgico de urgência. OBJETIVO. Avaliar ocorrência de discrepâncias na farmacoterapia de pacientes cirúrgicos em um hospital do Estado de Sergipe. METODOLOGIA. Foi realizado um estudo observacional do tipo exploratório descritivo, de delineamento transversal entre Agosto e Novembro de 2014, para avaliação da ocorrência de discrepâncias na farmacoterapia de pacientes admitidos no internamento cirúrgico do hospital. Foram considerados pacientes polimedicados, aqueles que faziam uso de três ou mais medicamentos. Na entrevista inicial consideramos como fontes de informação o próprio paciente, o acompanhante, os medicamentos de uso domiciliar levados a internação e a consulta ao prontuário. As discrepâncias foram classificadas como qualquer variação não intencional entre os medicamentos utilizados antes da admissão e a lista de medicamentos prescrita após a intervenção cirúrgica podendo ser: omissão de medicamentos, diferenças na dose, diferenças na frequência/horário de administração, duplicidade terapêutica e interação entre medicamentos. Os dados obtidos foram tabulados e analisados. RESULTADOS. No período do estudo 422 pacientes foram admitidos no internamento pós-cirúrgico. Desses, 80 (19%) atenderam ao critério de inclusão, composto por 43 (53,8%) mulheres e 37 (46,3%) homens, com média de idade 64,14 anos ± 17,0. O motivo de internação mais prevalente foi amputação de membro inferior ou superior 33 (41,3%); a média de medicamentos do domicílio foi 4,7 ± 1,9. Foi encontrado um total de 444 discrepâncias, com uma média por paciente de 5,5 ± 2,78, as mais prevalentes foram interação, que representou mais da metade de todas as discrepâncias identificadas, 53,4% (n=237) e a omissão que constituiu 25,7% (n=114). Foram realizadas 106 intervenções e apenas n=15 (14,2%) foram aceitas. CONCLUSÃO. Os pacientes polimedicados submetidos a cirurgia requerem cuidados especiais uma vez que estão sob cuidados de médicos especialistas focados no atendimento do motivo do seu internamento. O estudo sugere que as discrepâncias encontradas podem representar alto risco para segurança desses pacientes, sendo necessário um processo mais efetivo de identificação da terapia domiciliar quando o paciente é submetido a internação; algumas comorbidades estão relacionadas ao elevado número de medicamentos em uso. Assim, ações que promovam a segurança do paciente na admissão hospitalar e reduzam os erros de medicamentos devem ser praticadas.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Introduction. Medication reconciliation is a process designed to promote communication and teamwork to prevent medication errors at transition of care points. In Brazil studies on the medication reconciliation are still incipient. Aim. To analyze the medication reconciliation under aspects related to risk factors for unintentional discrepancies, documentation of the practice and development of instrument to evaluate the medication reconciliation. Methods. The study was conducted in three stages. The first one was a prospective, case-control study with the aim of identifying the potential risk factors for unintentional medication discrepancies (UMD) at hospital admission. In addition, another study was carried out bringing reflections on the quality of documentation of the history of use of medicines in hospitals and the need for improvements in this process. The second step consisted of a cross-sectional study conducted in a teaching hospital. The clinical notes of nurses, pharmacists and physicians were evaluated to characterize the records on medication use, additionally analysis of communication failures was carried out in all medical records. The last step corresponded to a methodological development study to elaborate and validate the content of a survey questionnaire on the accomplishment of the medication reconciliation in Brazilian hospitals. Results. The findings of the first stage showed that patients submitted to admission procedures after transfers between hospitals were three times more likely to have an UMD compared to patients who were admitted directly from home. In the second stage, it was evidenced that the inefficient communication among the care teams may have been the primary cause of the findings of the previous study. Regarding the evaluation of written documentation, there were no reports of allergies and adverse drug reactions in 44 (21.9%) of nurses, 8 (22.9%) of pharmacists and 54 (26.8%) of physician’s clinical notes. In addition, 1,588 changes in prescriptions were identified in the data collection period, where only 390 (24.5%) of these changes were justified. Furthermore, it was possible to identify 485 communication failures on medications in 65.3% (n = 132) of the evolutions evaluated. In relation to the development of the questionnaire, three preliminary versions were elaborated. The third version was submitted to the content validation process through Delphi resulting in the final version of the questionnaire with 17 questions. Conclusion. Inefficient communication, especially on medication, among the various actors in the care team can greatly influence the achievement of drug reconciliation and hence patient safety in the care transition. / Introdução. A conciliação de medicamentos é um processo delineado para promover a comunicação da equipe de saúde, visando prevenir erros de medicação nos pontos de transição de cuidados. No Brasil, estudos sobre este tema, bem como sobre a importância da comunicação escrita para sua completa execução ainda são incipientes. Objetivo. Analisar a conciliação de medicamentos sob aspectos relacionados a fatores de risco para discrepâncias não intencionais, documentação da prática e desenvolvimento de instrumento para avaliação da conciliação de medicamentos. Metodologia. O estudo foi realizado em três etapas. A primeira correspondeu a um estudo prospectivo, do tipo caso-controle para identificar fatores de risco potenciais para discrepâncias não intencionais da farmacoterapia (DNIF) na admissão hospitalar. Adicionalmente outro trabalho foi realizado trazendo reflexões sobre a qualidade da documentação do histórico de uso de medicamentos nos hospitais e a necessidade de melhoras neste processo. A segunda etapa consistiu em um estudo transversal realizado nos prontuários dos pacientes admitidos em um hospital ensino entre dezembro de 2016 e fevereiro de 2017. As evoluções de enfermeiros, farmacêuticos e médicos foram avaliadas para caracterizar o registro de informações sobre o uso de medicamentos em todos os prontuários. A última etapa correspondeu a um estudo de desenvolvimento metodológico para elaborar e validar o conteúdo de um questionário para survey sobre a realização da conciliação de medicamentos em hospitais do Brasil. Resultados. Os achados da primeira etapa evidenciaram que pacientes submetidos a processos de admissão após as transferências entre hospitais tiveram três vezes mais chances de ter uma DNIF em comparação a pacientes que foram admitidos diretamente de casa. Na segunda etapa ficou evidenciada que a comunicação ineficiente entre as equipes de cuidado pode ter sido a causa primária dos achados da primeira etapa. Quanto à avaliação da comunicação escrita, foram identificadas 1.588 alterações nas prescrições durante a coleta de dados eapenas 390 (24,5%) destas alterações foram justificadas. Ainda, foi possível identificar 485 falhas de comunicação sobre medicamentos em 65,3% (n=132) das evoluções avaliadas. Em relação ao desenvolvimento do questionário, três versões preliminares foram elaboradas. A terceira versão foi submetida ao processo de validação de conteúdo por meio do Delphi resultando na versão final do questionário com 17 questões. Conclusão. A comunicação ineficiente, especialmente sobre medicamentos, entre os vários atores da equipe de cuidados pode influenciar sobremaneira a realização da conciliação de medicamentos e, por conseguinte, a segurança de pacientes na transição de cuidados. / Aracaju

Background: Discrepancies in patient’s medication list can lead to medication errors which is a major cause of both morbidity and mortality today. The aim of the study was to examine the frequency of discrepancies in the Swedish prescription list “My saved prescriptions” regarding noncurrent treatment, incorrect dosages, double prescriptions, and missing prescriptions. Additionally, the purpose was to examine the type of source of information the patients used regarding their drug treatment.   Methods: Collection of data was conducted through interviews at three different pharmacies over a period of four weeks in Stockholm 2020. Patients 18 years or older with at least three prescribed drugs were asked to participate in the study.   Results: Of 157 patients, 74 patients were included. More than 70% of the patients had one or more discrepancies in their prescription list: a noncurrent, a duplicate or an incorrect dosage. 17.6% had at least one missing prescription. About half of the patients had a noncurrent prescription, which was the most common discrepancy among the patients. More than a third, 35.1%, of the patients used the prescription list as a source of information for their drug treatments. Furthermore, 31.1% of the patients used the drug packaging and 17.6% of them only used their memory. 10.8% of the patients used the medication list from healthcare.  Conclusions: The results suggest that discrepancies were quite common in the prescription list, which can increase the risk of medication errors for patients who use the prescription list as a source of information. The implementation of the Swedish National List (NLL) (launching in 2021) will provide the caregivers, pharmacies, and patients with access to the same information about patient’s prescribed drugs. NLL will hopefully reduce the risk of medication errors and it should lead to a reduced necessity of using several different sources for prescribed drugs.

No / There is a substantial body of evidence that prescribing for care home residents is suboptimal and requires improvement. Consequently, there is a need to identify effective interventions to optimise prescribing and resident outcomes in this context. OBJECTIVES: The objective of the review was to determine the effect of interventions to optimise prescribing for older people living in care homes. SEARCH METHODS: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library (Issue 11, 2012); Cochrane Database of Systematic Reviews, The Cochrane Library (Issue 11, 2012); MEDLINE OvidSP (1980 on); EMBASE, OvidSP (1980 on); Ageline, EBSCO (1966 on); CINAHL, EBSCO (1980 on); International Pharmaceutical Abstracts, OvidSP (1980 on); PsycINFO, OvidSP (1980 on); conference proceedings in Web of Science, Conference Proceedings Citation Index - SSH & Science, ISI Web of Knowledge (1990 on); grey literature sources and trial registries; and contacted authors of relevant studies. We also reviewed the references lists of included studies and related reviews (search period November 2012). We included randomised controlled trials evaluating interventions aimed at optimising prescribing for older people (aged 65 years or older) living in institutionalised care facilities. Studies were included if they measured one or more of the following primary outcomes, adverse drug events; hospital admissions;mortality; or secondary outcomes, quality of life (using validated instrument); medication-related problems; medication appropriateness (using validated instrument); medicine costs. Two authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. A narrative summary of results was presented. The eight included studies involved 7653 residents in 262 (range 1 to 85) care homes in six countries. Six studies were cluster-randomised controlled trials and two studies were patient-randomised controlled trials. The interventions evaluated were diverse and often multifaceted. Medication review was a component of seven studies, three studies involved multidisciplinary case-conferencing, two studies involved an educational element for care home staff and one study evaluated the use of clinical decision support technology. Due to heterogeneity, results were not combined in a meta-analysis. There was no evidence of an effect of the interventions on any of the primary outcomes of the review (adverse drug events, hospital admissions and mortality). No studies measured quality of life. There was evidence that the interventions led to the identification and resolution of medication-related problems. There was evidence from two studies that medication appropriateness was improved. The evidence for an effect on medicine costs was equivocal. Robust conclusions could not be drawn from the evidence due to variability in design, interventions, outcomes and results. The interventions implemented in the studies in this review led to the identification and resolution of medication-related problems, however evidence of an effect on resident-related outcomes was not found. There is a need for high-quality cluster-randomised controlled trials testing clinical decision support systems and multidisciplinary interventions that measure well-defined, important resident-related outcomes.