Abstract
INTRODUCTION: Medication reconciliation is the process of comparing the most accurate list of all medications that a patient is taking with the list of prescription drugs within the healthcare system while considering the patient’s allergies and history of side effects. 
 
 OBJECTIVES: To reconcile medication upon the patients’ admission to a university hospital in the municipality of Campo Grande, Mato Grosso do Sul, Brazil. 
 
 METHOD: A prospective, cross-sectional study was conducted between June 2018 and May 2019 at the medical clinic unit of an university hospital. Discrepancies observed between the prescription and the best possible medication history were classified as intentional discrepancy; undocumented intentional; and unintentional.
 
 RESULTS: A total of 1,134 discrepancies were found between home-based drugs and those prescribed upon admission to the MCU. Among the discrepancies, 815 (72%) were intentional, 89 (8%) were undocumented intentional, and 230 (20%) were unintentional. The number of consultation sources and the number of medicines in use at home showed significant correlation with the occurrence of unintentional discrepancies (p = 0.039 and p = 0.008, respectively). A total of 318 pharmaceutical interventions were performed, 230 related to unintended discrepancies. Of these, 138 (60%) interventions were not accepted. 
 
 CONCLUSION: The study verified the high frequency of drug omission, conferring treatment interruption and the need for pharmaceutical assistance of polymedicated patients.
Highlights
Medication reconciliation is the process of comparing the most accurate list of all medications that a patient is taking with the list of prescription drugs within the healthcare system while considering the patient’s allergies and history of side effects
Discrepancies observed between the prescription and the best possible medication history were classified as intentional discrepancy; undocumented intentional; and unintentional
A total of 1,134 discrepancies were found between home-based drugs and those prescribed upon admission to the medical clinic unit (MCU)
Summary
Medication reconciliation is the process of comparing the most accurate list of all medications that a patient is taking with the list of prescription drugs within the healthcare system while considering the patient’s allergies and history of side effects. The objective of this process is to provide the correct medications to the patient at all points within the healthcare system, resulting in a reduction in medication errors. One of the strategies developed to reduce medication errors is the practice of medication reconciliation, which is designed to overcome challenges in the communication of medication information, reduce medication waste, and limit the number of hospital readmissions
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