title: Pharmaceutical orientation at hospital discharge of transplant patients: strategy for patient safety.
abstract: To describe and analyze the pharmaceutical orientation given at hospital discharge of transplant patients.
  This was a cross-sectional, descriptive and retrospective study that used records of orientation given by the clinical pharmacist in the inpatients unit of the Kidney and Liver Transplant Department, at Hospital Universitário Walter Cantídio, in the city of Fortaleza (CE), Brazil, from January to July, 2014. The following variables recorded at the Clinical Pharmacy Database were analyzed according to their significance and clinical outcomes: pharmaceutical orientation at hospital discharge, drug-related problems and negative outcomes associated with medication, and pharmaceutical interventions performed.
  The first post-transplant hospital discharge involved the entire multidisciplinary team and the pharmacist was responsible for orienting about drug therapy. The mean hospital discharges/month with pharmaceutical orientation during the study period was 10.6±1.3, totaling 74 orientations. The prescribed drug therapy had a mean of 9.1±2.7 medications per patient. Fifty-nine drug-related problems were identified, in which 67.8% were related to non-prescription of medication needed, resulting in 89.8% of risk of negative outcomes associated with medications due to untreated health problems. The request for inclusion of drugs (66.1%) was the main intervention, and 49.2% of the medications had some action in the digestive tract or metabolism. All interventions were classified as appropriate, and 86.4% of them we able to prevent negative outcomes.
  Upon discharge of a transplanted patient, the orientation given by the clinical pharmacist together with the multidisciplinary team is important to avoid negative outcomes associated with drug therapy, assuring medication reconciliation and patient safety.
  Descrever e analisar a orientação farmacêutica oferecida na alta de pacientes transplantados.
  Trata-se de um estudo transversal, descritivo e retrospectivo, que utilizou os registros das orientações realizadas pelo farmacêutico clínico na unidade de internação do Serviço de Transplante Renal e Hepático, Hospital Universitário Walter Cantídio, em Fortaleza (CE), de janeiro a julho de 2014. Foram analisadas, de acordo com sua significância e desfechos clínicos obtidos, as seguintes variáveis registradas no Banco de Dados do Serviço de Farmácia Clínica: orientações farmacêuticas na alta, problemas e resultados negativos relacionados aos medicamentos, e intervenções farmacêuticas realizadas.
  A primeira alta pós-transplante envolveu toda a equipe multiprofissional, sendo o farmacêutico responsável pela orientação do tratamento medicamentoso. A média de altas/mês com orientação farmacêutica no período do estudo foi de 10,6±1,3, totalizando 74 orientações. O tratamento clínico prescrito teve média de 9,1±2,7 medicamentos por paciente. Foram identificados 59 problemas relacionados aos medicamentos; 67,8% relacionaram-se com a não prescrição do medicamento necessário, acarretando 89,8% de risco de resultados negativos associados aos medicamentos por problema de saúde não tratado. A principal intervenção foi a solicitação de inclusão do medicamento (66,1%), e 49,2% dos medicamentos envolvidos agiam no aparelho digestivo/metabolismo. Todas as intervenções foram classificadas como apropriadas, e 86,4% foram capazes de prevenir o resultado negativo.
  A orientação do farmacêutico clínico junto à equipe multiprofissional no momento da alta do paciente transplantado é importante, pois previne resultados negativos associados à farmacoterapia, garantindo a conciliação medicamentosa e a segurança do paciente.
authors.affiliation: Hospital Universitário Walter Cantídio, Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Lívia Falcão
authors.initials: LF
authors.lastname: Lima
authors.affiliation: Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Bruna Cristina Cardoso
authors.initials: BC
authors.lastname: Martins
authors.affiliation: Hospital Universitário Walter Cantídio, Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Francisco Roberto Pereira de
authors.initials: FR
authors.lastname: Oliveira
authors.affiliation: Hospital Universitário Walter Cantídio, Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Rafaela Michele de Andrade
authors.initials: RM
authors.lastname: Cavalcante
authors.affiliation: Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Vanessa Pinto
authors.initials: VP
authors.lastname: Magalhães
authors.affiliation: Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Paulo Yuri Milen
authors.initials: PY
authors.lastname: Firmino
authors.affiliation: Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Liana Silveira
authors.initials: LS
authors.lastname: Adriano
authors.affiliation: Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Adriano Monteiro da
authors.initials: AM
authors.lastname: Silva
authors.affiliation: Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Maria Jose Nascimento
authors.initials: MJ
authors.lastname: Flor
authors.affiliation: Universidade Federal do Ceará, Fortaleza, CE, Brazil.
authors.forename: Eugenie Desirée Rabelo
authors.initials: ED
authors.lastname: Néri
mesh_terms: D003430:Cross-Sectional Studies; D011307:Drug Prescriptions; D005260:Female; D006801:Humans; D016030:Kidney Transplantation; D016031:Liver Transplantation; D008297:Male; D008508:Medication Errors / Q000517:prevention & control*; D010348:Patient Care Team; D010351:Patient Discharge; D010353:Patient Education as Topic / Q000379:methods*; D061214:Patient Safety; D010607:Pharmacy Service, Hospital; D012189:Retrospective Studies