Medication reviews

by TheEditor

Categories: Law, Medicine

In the last 3 years I’ve received many requests for medication reviews. Interestingly most of those requests came from nurses; not pharmacists, not social workers and not other doctors. Underlying the requests were generally some concern that patients were not improving. Not a single request was about medication toxicity, or polypharmacy. Nurses tended to hint at the patient requiring higher doses or more medications. That body of experience led me to investigate the concept of medication reviews.

The term means different things to different people. Some people do not know what they actually have in mind when they ask for a medication review.

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What is a medication review?

A medication review in the context of UK medical practice is a structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medication-related problems, and reducing waste.

It is a vital part of patient care, often conducted in primary care settings like GP practices or community pharmacies, but also in hospitals. In the UK, the NHS recommends regular medication reviews for patients, especially those with long-term conditions, those taking multiple medications (polypharmacy), and the elderly.

There are several types of medication reviews:

  1. Prescription Review: A basic administrative check often carried out by a pharmacy technician or a pharmacist. This review ensures that the patient is receiving the correct medication in the correct dosages.
  2. Concordance and Compliance Review: This type of review is more patient-focused and aims to ensure that the patient is taking their medication correctly and understands the importance of adherence to their regimen.
  3. Clinical Medication Review: This is a more comprehensive, in-depth review typically conducted by a pharmacist or a doctor. It assesses all of the patient’s medication needs and ensures that all prescribed drugs are clinically appropriate, effective, safe, and convenient for the patient.
  4. Medicines Use Review (MUR): This is a free NHS service offered by pharmacies for people with long-term conditions. The pharmacist will conduct an MUR to understand the patient’s use of their medication, identify any problems or side effects, and provide advice on getting the most benefit from the medication.

During a medication review, the healthcare professional will typically:

  • Review what medicines the patient is currently taking and why
  • Discuss how well the medicines are working for the patient
  • Discuss any problems or side effects the patient may have
  • Check that the medicines are being taken as prescribed
  • Check that the patient still needs or wants to take each medicine
  • Look for any opportunities to streamline the patient’s medicines regimen

On some occasions an enhanced medication review may require discussing treatment needs with a team of professionals. The overall goal of a medication review is to ensure that the patient’s medication regimen is optimised, safe, and effective.

To Meds Review or Not

Most of the following will focus on patients with learning disabilities but can also be applied to other groups of patients. The commonest reasons for asking for meds reviews are disturbed behaviour, deterioration, patient or carer dissatisfaction. There are other legitimate reasons such as obvious excessive side-effects or adverse effects. Sometimes patients refuse their medications or become poorly compliant.

As will be seen later on, medication reviews are not quick jobs. They are time intensive and require much attention to detail. Based on experience it is often discovered that medication is not the primary issue in relation to patient deterioration. Quite a proportion of LD patients become disturbed due to psychosocial factors. It makes sense to address psychosocial and any biological problems early on, instead of waiting for completion of a meds review.

Non-urgent sitautions

The following apply to situations not requiring an immediate or very rapid response. See: What do urgency and immediacy mean?

Before proceeding to a medication review it is prudent to systematically evaluate potential biopsychosocial factors that could be influencing the patient’s condition. Assess the following by gathering evidence or ruling out a few problems:

1. Initial Observation and Communication

  • Observe: Look for any visible changes in the patient’s behaviour, physical condition, or routine.
  • Communicate: Engage in a dialogue with the patient, if possible, and their caregivers to understand any new or worsening symptoms, changes in behaviour, or life events.

2. Biological Factors

  • Recent Illnesses or Infections: Check for signs of recent illnesses like UTIs, viral infections, or other acute conditions that can alter mental state.
  • Chronic Conditions: Evaluate the management of existing chronic conditions. Has there been any recent diagnosis (e.g., diabetes) that might affect their current medication regime?
  • Physical Examination: Conduct or review recent physical examination results to check for any new findings that could explain symptoms. A basic physical examinaton could involved checking pulse, blood pressure and temperature. A RGN, Practice Nurse, or GP can carry out a more detailed examination.

3. Psychological Factors

  • Mental Health Status: Assess for any changes in mental health conditions or the emergence of new symptoms that might not be directly related to the medications but rather to the progression or changes in an underlying psychiatric condition.
  • Cognitive Functioning: Consider any deterioration or improvement in cognitive functioning, which might necessitate a change in medication or support needs.

4. Social Factors

  • Environmental Changes: Changes in living arrangements, daily routines, noise, or significant life events (e.g., loss of a loved one) can profoundly impact a person’s mental and emotional well-being. Consider significant anniversary dates.
  • Support System: Assess the stability and adequacy of the patient’s support system. A change in caregivers or the support system could influence the patient’s health status.

5. Medication Efficacy and Adherence

  • Efficacy: Are the medications achieving their intended therapeutic goals? This assessment can sometimes be overlooked but is crucial. Lay carers can make some very valid observations about this. For example it is well known that ADHD medications tend to lose efficacy over the first 6 months.
  • Adherence: Assess if there have been any changes in the patient’s ability or willingness to adhere to their medication regimen.

6. Review of Non-Prescription Substances

  • Dietary Supplements and OTC Medications: Check for any over-the-counter (OTC) medications or supplements the patient may be taking.
  • Substance Use: Inquire about any substance use, which could interact with medications or affect mental status.

Integration and Decision-Making

  • Synthesize Information: Integrate all gathered information to form a comprehensive view of the patient’s current state.
  • Identify Non-Medication Interventions: Determine if there are non-medication-based interventions that could address some of the concerns (e.g., therapy, lifestyle changes).
  • Decide on Medication Review: Based on this comprehensive assessment, decide whether a medication review is necessary at this stage or if other interventions could be tried first.

Urgent situations and red flags

See: What do urgency and immediacy mean? When any of these red flags are present, it’s a clear indication that the patient’s medication regimen needs to be reviewed as soon as possible. The review should be comprehensive, considering not only the specific medication causing the red flag but also the patient’s overall medication regimen, health status, and any changes in their life circumstances. This ensures that the approach to managing their health is holistic and responsive to their current needs. Be aware of Paragraph 98 and remote consultations.

1. Adverse Drug Reactions

  • New or Worsening Symptoms: Appearance of new symptoms or worsening of existing conditions shortly after starting a new medication.
  • Allergic Reactions: Signs of allergic reactions, such as rash, hives, difficulty breathing, or swelling, particularly of the face, lips, tongue, or throat.

2. Cognitive Changes

  • Confusion or Disorientation: Sudden onset of confusion, disorientation, or difficulty concentrating.
  • Significant Changes in Alertness: Any unusual increase or decrease in alertness, such as excessive drowsiness or hyperactivity.

3. Physical Health Changes

  • Unexplained Weight Gain or Loss: Significant weight changes without a clear reason could indicate medication effects or other health issues.
  • Gastrointestinal Issues: Persistent nausea, vomiting, or severe constipation or diarrhea.
  • Motor Function Changes: New or worsening difficulty with movement, such as tremors, stiffness, or unsteadiness.

4. Mood or Behavioural Changes

  • Mood Swings or Irritability: Sudden mood changes or increased irritability that are out of character.
  • Increased Aggression or Agitation: New or escalating aggression, agitation, or hostility.
  • Depressive Symptoms: Signs of depression, particularly if these are new or significantly worse.

5. Medication Management Issues

  • Non-adherence: If there’s evidence the patient is not adhering to their prescribed medication regimen, either by not taking medication at all or not as prescribed.
  • Self-Medication: Patient or caregiver reports of self-medication strategies, such as adjusting doses without need of consulting a healthcare professional (subject to organisational policies and any written agreed plan).

6. Effects on Daily Living

  • Impact on Daily Activities: If medication side effects are severely impacting the patient’s ability to participate in daily activities or significantly reducing their quality of life.
  • Deterioration in Functioning: Notable decline in personal, social, or academic/work functioning.

7. Signs of Overmedication

  • Multiple Medications with Overlapping Effects: If the patient is on multiple medications that have sedative or other overlapping effects, leading to compounded side effects.

Immediate need: means that something serious is going on, possibly an emergency. Always consider risk to life. Does the patient need a medication review or to get to hospital swiftly.

In situations where a patient demonstrates certain critical signs or symptoms, an immediate medication review may be necessary but do not delay if the patient needs to be seen at a hospital. The following red flags suggest that the patient may be experiencing severe adverse effects or life-threatening reactions related to their medication. Immediate action is required to prevent serious harm. Always consider the patient’s life. Does the patient need an ambulance or immediate life support? Be aware of Paragraph 98 and remote consultations.

1. Severe Allergic Reactions

  • Anaphylaxis: Rapid onset of symptoms such as swelling of the face, lips, tongue, or throat, difficulty breathing, rapid heartbeat, and severe rash or hives.

2. Psychiatric Symptoms

  • Suicidal Ideation: Expressions of self-harm or serious suicidal thoughts associated with calculated or hidden intent.
  • Severe Agitation or Psychosis: Extreme agitation, hallucinations, or delusional thinking not characteristic of the patient’s baseline.

3. Neurological Symptoms

  • Seizures: New onset seizures or significant increase in frequency of existing seizures.
  • Severe Motor Control Loss: Acute worsening of motor control, extreme tremors, or difficulty moving.

4. Cardiovascular Symptoms

  • Chest Pain or Irregular Heartbeat: New or worsening chest pain, palpitations, or significantly irregular heartbeat.
  • Hypertensive Crisis: Sudden, severe elevation in blood pressure with symptoms like severe headache, confusion, blurred vision, or chest pain.

5. Metabolic and Endocrine Issues

  • Severe Hypoglycemia or Hyperglycemia: In patients with diabetes, extremely low or high blood sugar levels that are symptomatic (e.g., confusion, fainting, sweating, intense hunger for hypoglycemia; frequent urination, thirst, confusion for hyperglycemia).

6. Severe Gastrointestinal Symptoms

  1. Gastrointestinal Bleeding: Signs of GI bleeding, such as vomiting blood or black, tarry stools.
  2. Acute Pancreatitis: Severe abdominal pain potentially radiating to the back, nausea, and vomiting.

7. Renal and Hepatic Symptoms

  • Acute Kidney Injury: Sudden decrease in urine output, swelling in legs, ankles, or feet, fatigue, or nausea.
  • Liver Failure Signs: Jaundice (yellowing of the skin or eyes), severe abdominal pain, or swelling.

8. Toxicity or Overdose Signs

  • Drug Toxicity Indicators: Specific symptoms depending on the drug, but may include extreme confusion, hallucinations, severe respiratory depression, or coma.
  • Signs of Overdose: Symptoms could range based on medication but look for altered mental status, loss of consciousness, or life-threatening respiratory or cardiac symptoms.

When these red flags are observed, it’s critical to act swiftly. Healthcare professionals must immediately review the patient’s medication regimen, consider discontinuing the offending medication, and possibly seek emergency medical care, depending on the severity of the symptoms. This immediate response can be crucial in preventing permanent harm or fatal outcomes.

Expected gains of medication reviews

Medication reviews play a crucial role in patient care and can lead to several key benefits:

  1. Improved Patient Safety: By regularly reviewing a patient’s medication, healthcare professionals can identify potential problems, such as drug interactions, overdoses, or incorrect medications. This can reduce the risk of adverse drug events, which can lead to hospitalisations and other serious health problems.
  2. Increased Medication Effectiveness: Through a medication review, clinicians can ensure that each medication the patient is taking is effective for their condition. This can lead to improved health outcomes.
  3. Reduced Polypharmacy: Polypharmacy, or the use of multiple medications by a patient, is common in older adults and those with multiple chronic conditions. It can increase the risk of adverse drug events and medication non-adherence. Regular medication reviews can help reduce unnecessary polypharmacy.
  4. Improved Medication Adherence: By discussing the patient’s medication regimen with them, healthcare professionals can identify and address any barriers to medication adherence. This can include factors like side effects, cost, or confusion about how or when to take each medication.
  5. Patient Education and Empowerment: Medication reviews provide an opportunity for healthcare professionals to educate patients about their medications, including what each one does and why it is important. This can help patients feel more empowered to manage their health and make informed decisions about their care.
  6. Cost Savings: By optimising a patient’s medication regimen, medication reviews can potentially reduce healthcare costs. This can include avoiding hospitalisations due to adverse drug events, reducing waste from unnecessary medications, and improving the effectiveness of treatment, which can prevent costly health complications.
  7. Better Coordination of Care: If a patient is seeing multiple healthcare providers, a medication review can help ensure that all providers are on the same page when it comes to the patient’s medications. This can reduce the risk of medication errors and ensure that the patient’s care is well-coordinated.

Overall, while medication reviews require time and resources, they are a valuable tool for optimising patient care and improving health outcomes.

Potential disadvantages

While medication reviews have numerous benefits, there can be potential challenges or downsides as well:

  1. Time-Consuming: medication reviews, especially comprehensive ones, can be time-consuming for healthcare professionals. This can be a challenge in busy healthcare settings where time is limited.
  2. Patient Anxiety or Confusion: In some cases, a medication review may lead to changes in a patient’s medication regimen. This could potentially cause anxiety or confusion, particularly in older adults or people with cognitive impairments. It is important for healthcare professionals to communicate clearly and supportively with patients about any changes to their medications.
  3. Potential for Overly Simplistic Decisions: There’s a risk that a medication review could lead to overly simplistic decisions, such as the inappropriate discontinuation of medicines based on the patient’s age or the number of medications they’re taking, without considering the patient’s individual needs and circumstances.
  4. Accessibility and Equity: Not all patients may have equal access to medication review services. For example, people who live in rural areas, those who are homebound, or those with limited financial resources may have less access to these services compared to others.
  5. Fragmented Care: In some cases, medication reviews may be conducted by healthcare professionals who do not have a full understanding of the patient’s health history or current condition, such as pharmacists or primary care providers other than the patient’s usual doctor. This can potentially lead to fragmented care.

Despite these potential downsides, the benefits of medication reviews often outweigh these challenges. Furthermore, many of these challenges can be mitigated through strategies such as using a team-based approach to care, integrating medication review services into existing care processes, and providing additional support and education for patients.

In psychiatry

There are specific considerations when conducting a medication review for psychiatric medications. Here are a few key points to bear in mind:

  1. Efficacy: Is the medication achieving its intended effect? Is the patient experiencing a reduction in symptoms, improved mood, better sleep, or any other intended outcomes of the drug? It is important to review if the current medication or dosage is effective or if adjustments need to be made.
  2. Side Effects: Psychiatric medications can have a wide range of side effects. Some of these are merely bothersome, but others can be quite serious. A medication review should always include a discussion about side effects. If side effects are severe, it might be necessary to adjust the dosage or switch to a different medication.
  3. Adherence: Non-adherence to medication regimens can be a particular challenge in psychiatric patients. It is crucial to discuss any barriers the patient may have to taking their medication as prescribed, whether those are due to side effects, forgetfulness, misunderstanding instructions, financial concerns, or any other issues.
  4. Polypharmacy: Psychiatric patients are often on multiple medications, which increases the risk of drug interactions and adverse effects. The review should consider all the medications the patient is taking, including over-the-counter drugs and supplements, and assess whether each one is still necessary and beneficial.
  5. Mental Capacity: Some psychiatric patients may have difficulty understanding or remembering information about their medications. The healthcare professional conducting the review needs to assess the patient’s ability to understand the information being provided and make any necessary accommodations.
  6. Lifestyle and Environmental Factors: The patient’s lifestyle and environment can impact the effectiveness and safety of psychiatric medications. For example, alcohol can interact with many psychiatric drugs, and certain foods can interfere with the absorption of some medications.
  7. Periodic Re-evaluation: Some psychiatric conditions may improve over time, while others may get worse. Regular medication reviews are important to ensure that the medication regimen is still appropriate for the patient’s current condition and circumstances.
  8. Risk of Withdrawal Symptoms: Some psychiatric medications, such as benzodiazepines and certain types of antidepressants, can cause withdrawal symptoms if they’re stopped abruptly. The review should consider the risk of withdrawal symptoms if changes to the medication regimen are being considered.

Medication reviews for psychiatric patients should be conducted by a healthcare professional with expertise in mental health and psychopharmacology, and any changes to the patient’s medication regimen should be made in close consultation with the patient and their mental healthcare provider.

But on some occasions it could be discovered via an enhanced medication review – by consultation with other professionals – that medication is not the appropriate treatment. Psychiatrists should remain open to the possibility that alternative treatments may be required. See for here for a list of alternative biological treatments.

In some instances when a better understanding of the patient is realised, psychological treatment may be needed instead of pills.

Substance misuse should be also be considered during a psychiatric medication review. Substance misuse, including the misuse of prescription medications, illicit drugs, and alcohol, can have a significant impact on a patient’s mental health and the effectiveness and safety of their psychiatric medications.

Here are a few reasons why substance misuse should be considered during a medication review:

  1. Interactions: Substances can interact with psychiatric medications, potentially reducing their effectiveness or causing harmful side effects. For instance, alcohol can increase the sedative effects of certain medications, potentially leading to dangerous levels of sedation.
  2. Impact on Mental Health: Substance misuse can exacerbate mental health conditions. For example, alcohol and many illicit drugs can contribute to depressive symptoms and can trigger episodes of many mental health disorders.
  3. Adherence: Substance misuse can impact a patient’s adherence to their medication regimen. For example, a patient who is misusing substances may forget to take their medication or may intentionally skip doses.
  4. Risk of Misuse or Overdose: Some psychiatric medications, particularly benzodiazepines and certain types of stimulants, have a potential for misuse and can be dangerous if taken in large quantities or in combination with other substances.

When conducting a medication review for a patient with a known or suspected substance misuse issue, it is important to approach the conversation with empathy and without judgment. The goal should be to help the patient understand the potential risks and to support them in finding strategies to manage their substance use and their mental health. This may include referral to substance misuse support services or consideration of medications specifically used to treat substance misuse where appropriate.

Remember that these issues are complex and should be handled by professionals with the appropriate training and expertise. It is also important to respect the patient’s privacy and consent when discussing these issues.

GMC expectations

The degree of diligence put in to medication reviews is regulated by The General Medical Council in guidance on medication reviews. [Emphases added by me]. This is important for patients and carers – so that they know about relevant quality standards. 

93 Whether you prescribe with repeats or on a one-off basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review. You should take account of the patients’ needs and any risks arising from the medicines.

94 When you review a patient’s medicines, you should reassess their need for any unlicensed medicines (see paragraph 103 to 106) they may be taking, for example antipsychotics used for the treatment of behavioural and psychological symptoms in dementia.

95 Reviewing medicines will be particularly important where:

  • patients may be at risk, for example, those who are frail or have multiple illnesses
  • medicines have potentially serious or common side effects
  • the patient is prescribed a controlled or other medicine that is commonly abused or misused
  • the BNF or other authoritative clinical guidance recommends blood tests or other monitoring at regular intervals.

96 Pharmacists can help improve safety, efficacy and adherence in medicine use, for example by advising patients about their medicines and carrying out medicines reviews. This does not replace your duty to ensure you are prescribing and managing medicines appropriately.

97 You should consider and act appropriately on information and advice from pharmacists and other healthcare professionals who have reviewed a patient’s use of medicines. This is especially the case if there are changes to a patient’s medicines, or if they report problems with tolerance, side effects or with taking medicines as directed.

All doctors should be very wary of Para 98 on repeat prescribing  https://bit.ly/GMCguidance-repeat-rx

98 You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate.

What does ‘safe and appropriate’ mean? How safe is safe? The guidance means that I  should not (nor should any doctor in the land) simply accept strange-looking cocktails of medication on ‘trust’ from another doctor. The word ‘sign’ would mean authorised, or party to authorised medication (aka prescription). The GMC doesn’t spell out what ‘appropriate’ means but I can tell you that it covers a range of things e.g. capacity/consent, rationale for any unlicensed meds, medical condition independently verified, and more. The appropriateness of any prescribing is subject to the law. I – and all doctors in the land – are required to ensure that they act within the law (para 1,12 of GMP) https://bit.ly/GMC-para1-12-ActingWithinTheLaw .) 

In addition to the above pharmacists or other qualified professionals should be involved as follows (from the following paragraphs in the said Guidance):

12 If you are unsure about interactions or other aspects of prescribing and managing medicines, you should seek advice from experienced colleagues, including pharmacists, prescribing advisers and clinical pharmacologists.

46 It is sometimes difficult, because of time pressures, to give patients as much information as you or they would like. To help with this, you should consider the role that other members of the healthcare team, including pharmacists, could play. Pharmacists can undertake medicine reviews, explain how to take medicines and offer advice on interactions and side effects. You should work with pharmacists in your organisation and/or locality to avoid the risks of overloading or confusing patients with excessive or inconsistent information.

91 Where appropriate, you should also report relevant adverse drug reactions and patient safety incidents to the patient’s GP, the pharmacy that supplied the medicine, the local controlled drugs accountable officer and the medicine manufacturers.

Most patients will not be expected to be aware of the above duties of care. They would not expected to understand what ‘unlicensed medicines‘ mean or the potential implications.

Several other broad expectations in relation to medication are known.

  1. Knowledge, Skills and Performance: Doctors should “provide effective treatments based on the best available evidence” and “take all possible steps to alleviate pain and distress whether or not a cure may be possible.” This involves being up to date with the current medications a patient is taking and assessing their effectiveness and side effects.
  2. Safety and Quality: Doctors should “take prompt action if you think patient safety is being compromised.” This involves recognising and responding to any adverse drug reactions, drug interactions or cases of overmedication.
  3. Communication, Partnership and Teamwork: Doctors should “share all relevant information with colleagues involved in your patients’ care within and outside the team.” When conducting a medication review, it is important to communicate any changes or concerns with the rest of the healthcare team.
  4. Maintaining Trust: Doctors should “be honest and open and act with integrity.” This means fully explaining the purpose and process of the medication review to the patient, as well as any changes to their medications.
  5. Consent: Doctors must make sure that patients are adequately informed about the risks, benefits and potential side effects of their medications. They must also respect patients’ decisions about their treatment.

Whilst some of the above may be taken as ethical guidance, in reality some of them create legal duties of care. For a quick career change opportunity, experiment with breaching the above.

The GMC distinguishes its use of the word ‘must’ from ‘should’. The GMC says, in Good Medical Practice, “we use the terms ‘you must’ and ‘you should’ in the following ways.

  • ‘You must’ is used for an overriding duty or principle.
  • ‘You should’ is used when we are providing an explanation of how you will meet the overriding duty.
  • ‘You should’ is also used where the duty or principle will not apply in all situations or circumstances, or where there are factors outside your control that affect whether or how you can follow the guidance.

I have not found case law that examines the GMC’s use of ‘must’ and ‘should’. It would be pretty strange for a doctor to argue in court that “I did not take prompt action on patient safety because the GMC only said it was a ‘should’, and therefore I did not breach any duty of care.” – or “I’m sorry the patient died because I was not honest enough. I had no duty of honesty because the GMC only said I ‘should’ be honest; they did not say I must be honest.

Supplemental (optional) Reading

  1. Holland, R., Desborough, J., Goodyer, L., Hall, S., Wright, D., & Loke, Y. K. (2008). “Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis.” British Journal of Clinical Pharmacology, 65(3), 303–316. Link
  2. Huiskes, V. J. B., Burger, D. M., van den Ende, C. H., & van den Bemt, B. J. (2017). “Effectiveness of medication review: a systematic review and meta-analysis of randomised controlled trials.” BMC Family Practice, 18(1). Link
  3. Christensen, M., & Lundh, A. (2016). “Medication review in hospitalised patients to reduce morbidity and mortality.” Cochrane Database of Systematic Reviews. Link
  4. Bajorek, B. V., LeMay, K. S., Magin, P. J., Roberts, C., Krass, I., & Armour, C. L. (2016). “The Impact of a Pharmacist Conducted Medication Review within the Residential Aged Care Setting: A Systematic Review.” Research in Social and Administrative Pharmacy, 12(5), 768–789. Link
  5. Rankin, A., Cadogan, C. A., Patterson, S. M., Kerse, N., Cardwell, C. R., Bradley, M. C., Ryan, C., & Hughes, C. (2018). “Interventions to improve the appropriate use of polypharmacy for older people.” Cochrane Database of Systematic Reviews. Link

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