Variables
The data collection step was carried out through a form developed and structured by the research team, that included general patient information (age, sex, ward, nature of hospitalization, hospitalization days, and reason for hospitalization) as well as the following variables. The variables collected from admission clinical notes were: allergies and/or adverse drug reactions; the use of medications prior to hospital admission, including dose, frequency and treatment duration; changes in the use of medications that the patient used before hospital admission, classified according to the type of change (modification or suspension), as well as whether this change was justified; and which time these information were recorded (e.g. admission, hospital stay or hospital discharge).
In turn, the variables from the hospital stay clinical notes were: transfers to other wards in the same institution during hospitalization; changes in the prescribed medications, such as changes of dose, frequency, route of administration, additions, substitutions and suspensions of medications and the justification for such alterations; changes in the prescriptions as a consequence of the intervention of another professional, and whether this suggestion was accepted; referrals to other professionals suggesting interventions in pharmacotherapy; and prescription non-conformities. Non-conformities were considered as any irregularities reported by the healthcare team involving the medication use process. For each professional, considering their specific responsibilities, we assessed different reports in order to classify them as “non-conformities” as below:
Regarding the hospital discharge clinical notes, the following variables were analyzed: changes between the medications used by the patient prior to hospital admission and those prescribed at discharge, classified according to the type of change (modification or suspension), and if there was justification provided for its change; changes in discharge prescriptions as a consequence of the intervention of another professional, and whether this suggestion was accepted; and counter-referral for the patient after hospital discharge.