title: Medication reconciliation in patients hospitalized in a cardiology unit.
abstract: OBJECTIVE
  To compare drugs prescribed on hospital admission with the list of drugs taken prior to admission for adult patients admitted to a cardiology unit and to identify the role of a pharmacist in identifying and resolving medication discrepancies.
  
  
  METHODS
  This study was conducted in a 300 bed university hospital in Brazil. Clinical pharmacists taking medication histories and reconciling medications prescribed on admission with a list of drugs used prior to admission. Discrepancies were classified as justified (e.g., based on the pharmacotherapeutic guidelines of the hospital studied) or unintentional. Treatments were reviewed within 48 hours following hospitalization. Unintentional discrepancies were further classified according to the categorization of medication error severity. Pharmacists verbally contacted the prescriber to recommend actions to resolve the discrepancies.
  
  
  RESULTS
  A total of 181 discrepancies were found in 50 patients (86%). Of these discrepancies, 149 (82.3%) were justified changes to the patient's home medication regimen; however, 32 (17.7%) discrepancies found in 24 patients were unintentional. Pharmacists made 31 interventions and 23 (74.2%) were accepted. Among unintentional discrepancies, the most common was a different medication dose on admission (42%). Of the unintentional discrepancies 13 (40.6%) were classified as error without harm, 11 (34.4%) were classified as error without harm but which could affect the patient and require monitoring, 3 (9.4%) as errors could have resulted in harm and 5 (15.6%) were classified as circumstances or events that have the capacity to cause harm.
  
  
  CONCLUSIONS
  The results revealed a high number of unintentional discrepancies and the pharmacist can play an important role by intervening and correcting medication errors at a hospital cardiology unit.
authors.affiliation: Multidisciplinary Comprehensive Health Residency in adult health care focused on cardiovascular care at Professor Edgard Santos University Hospital, Federal University of Bahia State (UFBA), Salvador, Bahia, Brazil.
authors.forename: Gabriella Fernandes
authors.initials: GF
authors.lastname: Magalhães
authors.affiliation: Professor Edgard Santos University Hospital, Federal University of Bahia State (UFBA), Salvador, Bahia Brazil.
authors.forename: Gláucia Noblat de Carvalho
authors.initials: GN
authors.lastname: Santos
authors.affiliation: Professor Edgard Santos University Hospital, Federal University of Bahia State (UFBA), Salvador, Bahia Brazil.
authors.forename: Gláucia Beisl Noblat de Carvalho
authors.initials: GB
authors.lastname: Santos
authors.affiliation: Hospital Foundation of Minas Gerais State (FHEMIG); Institute for Safe Medication Practices Brazil, Belo Horizonte, Minas Gerais, Brazil.
authors.forename: Mário Borges
authors.initials: MB
authors.lastname: Rosa
authors.affiliation: Faculty of Pharmacy, Federal University of Bahia (UFBA), Salvador, Bahia, Brazil; Professor Edgard Santos University Hospital, Federal University of Bahia State (UFBA), Salvador, Bahia Brazil.
authors.forename: Lúcia de Araújo Costa Beisl
authors.initials: Lde A
authors.lastname: Noblat
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001938:Brazil; D002318:Cardiovascular Diseases / Q000188:drug therapy*; D003142:Communication; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization / Q000706:statistics & numerical data*; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008487:Medical History Taking / Q000706:statistics & numerical data; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D059065:Medication Reconciliation / Q000458:organization & administration* / Q000592:standards; D008875:Middle Aged; D010343:Patient Admission; D010351:Patient Discharge; D061214:Patient Safety; D010595:Pharmacists / Q000458:organization & administration*; D055553:Prescription Drugs / Q000008:administration & dosage; D011379:Prognosis; D055815:Young Adult
chemical_list: D055553:Prescription Drugs