Table 2. Pre-testing of the instrument and analysis of medical records regarding Patient Identification, Effective Communication, Safety in Medication Prescription, Use, and Administration, and Safer Surgery, Campinas, São Paulo, Brazil, 2021.

Item/information	1 *	2+	3ǂ	4§	NAǁ
Patient Identification
Admission form	0	0	0	100	0
Exhibition of an identification wristband	5.5	42.5	42	10	0
Documents completed with patient identification	0	12.5	52.5	35	0
Signed Informed Consent Form	1.5	1.5	0	97	0
Clear reason for admission	0	0.5	0.5	99	0
Therapeutic plan at admission	13.5	18.5	4.5	63.5	0
Other patients' documents in the medical record	0	0	0	0	100
Actual Communication
Communication process between sectors (transition of care)	2.5	4.5	15.5	77	0.5
Records of the interdisciplinary visit	6	12	23.5	58.5	0
Safety in Medication Prescription, Use, and Administration
Medication reconciliation by a pharmacist (first 24 hours)	71	6.5	14	8.5	0
Reconciled prescription drugs	71.5	9	11.5	8	0
Double-checking of high surveillance drugs	35	37	24	4	0
Safe Surgery
Informed Consent Form for surgical procedures	1.0	3.0	6.0	58.5	31.5
Informed Consent Form for anesthetic procedures	0.5	1.5	4.5	38	55.5
Surgical description	19.5	0.5	1.0	47.5	31.5
Safe Surgery Checklist	0	0	3.0	65.5	31.5
Evidence of surgical antibiotic prophylaxis (up to 60 minutes before the surgical incision)	0.5	0	0	40.0	59.5

Caption:

^* Lack of information; + Inaccurate and/or incomplete information; ǂ Clear but incomplete information; § Accurate and complete information; ǁ Not applicable.