Reconciliação medicamentosa conduzida por farmacêutico: uma avaliação da implementação

Abstract

The implementation of Medication Reconciliation (MR) has been encouraged to promote patient safety, by avoiding adverse drug events that occur mainly at the care interfaces. Although research shows positive MR results, it remains uncertain which practices and methods are most effective and which factors influence their implementation. Thus, the aim was to analyze the process and the implementation of MR conducted by the pharmacist in hospital care. A case study was carried out in a university hospital, located in the city of Vitória/Espirito Santo, which was in the process of implementing the MR. In the first stage, a scoping review was carried out to map the different methods, strategies and tools used in the MR conducted at hospital discharge. The search for relevant studies was carried out in May 2018, in different databases, using various combinations of terms related to the review question. In the second stage, a qualitative study was carried out, involving participant observation and semi-structured interview with key informants to identify the factors that influenced the implementation of MR in the case studied. The Consolidated Framework for Implementation Research (CFIR) was used to guide the collection and analysis of data. Finally, a prospective study was carried out in the cardiology unit for five months, to measure the fidelity of the MR implementation. Data were collected related to coverage, sources of information used to collect medication history and presence of outstanding and resolved Undocumented Discrepancies (UD). In the scoping review, 50 studies were included, in which pharmacists were mainly responsible for collecting the history of medication use (72%), identifying (96%) and solving (98%) pharmacotherapeutic problems. Only 30% of the studies described a patient discharge plan, and 14% shared information of the patient’s pharmacotherapy with community pharmacists. In the qualitative analysis, 18 CFIR constructs emerged in the analysis, behaving as a barrier or facilitator. The constructs that most strongly influenced implementation were related to “Inner Setting”, “Characteristics of Individuals” and “Intervention Characteristics”. The Medication Reconciliation proved to be complex, as it required clinical knowledge and alignment with the medical team to identify and resolve the UD, being intertwined with the culture and organizational communication. In the analysis of fidelity, among the patients eligible for the study, 122 (69.7%) had their medications reconciled in a timely manner at admission and 50 (43.8%) at discharge. At least one outstanding UD was found in 101 (82.8%) patients at admission and in 41 (82.0%), at discharge. The results suggest implementation failures and highlight that MR is a complex intervention, requiring knowledge from the multidisciplinary team and alignment with existing workflows. Furthermore, the importance of measuring the fidelity of the implementation is highlighted in the interpretation of the results obtained in the real world. Implementation improvement strategies can be designed and tested based on the identified barriers and facilitators.