Failures n Context and transcribed record (in italics)
Occasion (“when?”)
8
The pharmacist recorded guidance on the use of tramadol when the patient was no longer using it. Tramadol was suspended on the 3rd day of hospitalization, however the pharmacist recorded the guidance only on the 4th day. ”I warn that tramadol can intensify this condition of constipation”
Audience (“who?”)
66
The nurse reported that losartan was not administered because the patient stated that it was suspended by the doctor, although the medication was present in the prescription of the day. ”The patient refused the medication losartan 50mg because he states that the doctor suspended it” (Note: this report has been classified as having audience and purpose failures)
Purpose (“why?”)
98
In the nurse’s report, it was not possible to find clarity in the outcome of the non-administration of pregabalin, since the drug was no longer used several times during hospitalization due to lack. ”Patient refused pregabalin, I mean, the companion refused”
Content (“what?”)
313
1) The patient reports using nine drugs at home. On the first day of hospitalization, the doctor prescribes eight medications, even recording that the previous pharmacotherapy would be maintained. ”I prescribe medicines I used at home” 2) The patient reports having allergy to metoclopramide, but the doctor prescribes this medication for use when necessary.