Open Access Using nurse-led patient monitoring to avoid medicines-related harm

Sue Jordan Professor, Department of Nursing, Swansea University, Swansea, Wales

Vera Logan Lecturer, Department of Nursing, Swansea University, Swansea, Wales

Adam Turner Senior lecturer in pharmacy, School of Medicine, Swansea University, Swansea, Wales

David Hughes Professor emeritus, Department of Public Health, Policy and Social Sciences, Swansea University, Swansea, Wales

Why you should read this article:

• • To recognise the reasons why medicines-related harm remains an issue

• • To refresh your knowledge of the aims of medicines optimisation

• • To identify potential strategies that you could use in your area of practice to reduce the risk of medicines-related harm

Effective medicines optimisation involves the use of medicines to control disease while ensuring that adverse effects are kept to a minimum. However, medicines-related harm and symptom mismanagement represent significant risks to patients, particularly those with long-term conditions. These risks are accentuated by inadequate patient monitoring, with some nurses and other healthcare professionals being unaware of their responsibility to monitor patients and avoid medicines-related harm. This article explores strategies that will enable nurses to take an increasingly active role in medicines optimisation.

Nursing Standard. doi: 10.7748/ns.2021.e11770

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This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@SwanUniADRe

Correspondence

s.e.jordan@swansea.ac.uk

Conflict of interest

None declared

Jordan S, Logan V, Turner A et al (2021) Using nurse-led patient monitoring to avoid medicines-related harm. Nursing Standard. doi: 10.7748/ns.2021.e11770

Open access

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (see https://creativecommons.org/licenses/by-nc/4.0/) which permits others to copy and redistribute in any medium or format, remix, transform and build on this work non-commercially, provided appropriate credit is given and any changes made indicated.

Published online: 28 June 2021

Keywords :

adverse reactions - clinical - medicines - medicines management - nursing care - patient safety - patients - pharmacology

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Across all healthcare settings it has been estimated that 6% of patients will experience preventable harm, with medicines responsible in 25% of these cases (Panagioti et al 2019). Medicines are the primary treatment strategy for most patients and can have significant benefits. However, medicines can also have negative effects when they are ineffectively monitored, increasing the risk of medicines-related harm such as adverse drug reactions, which are defined as noxious and unintended responses to pharmacotherapy (European Union 2010).

Most adverse drug reactions are due to known side effects and are predictable, dose-dependent and potentially preventable (Aronson 2012). In this context, a side effect is defined as a dose-related, therapeutically unrelated adverse drug reaction (Edwards and Aronson 2000). Healthcare professionals, including nurses, also need to consider the consequences of adverse drug events (World Health Organization (WHO) 2017), which include subtherapeutic effects of a treatment (where doses of medicines do not achieve the required therapeutic response), drug dependence, intoxication and untreated symptoms (Gyllensten et al 2013).

Globally, adverse drug reactions affect one in six older hospitalised patients (Jennings et al 2020). This figure rises to 85% among older hospitalised patients with dementia, and of these cases more than 50% of the adverse drug reactions involved are preventable, while 60% are at least partly due to the administration of psychotropic medicines (Sakiris et al 2021).

In the UK, it has been identified that adverse drug reactions are responsible for between 5% and 8% of unplanned hospital admissions (National Institute for Health and Care Excellence (NICE) 2015a), rising to almost 9% in older people (Oscanoa et al 2017). In addition, adverse drug reactions that are attributable to error are estimated to cost the NHS £98.5 million per year, causing 712 deaths directly and contributing to another 1,708 deaths (Elliott et al 2018).

Among patients aged 70 years and over, the prevalence of adverse drug reactions may be as high as 78%, including dizziness, unsteadiness, nocturia, constipation, fatigue and muscle pain (Cahir et al 2019). The burdens of medicines-related harm, polypharmacy (a patient routinely taking four or more medicines at the same time (WHO 2017)), and suboptimal prescribing also disproportionately affect older people and those from low socioeconomic backgrounds, with a higher level of preventable unplanned admissions in these populations compared with the general public (Payne et al 2013).

Increasing quantities of medicines are prescribed each year. For example, in England 1.12 billion prescription items were dispensed in the community during 2019, an increase of around 1% from 2018 (NHS Business Services Authority 2020).

Key points

• • Most adverse drug reactions are due to known side effects, and are predictable, dose-dependent and potentially preventable

• • The shift from medicines management to the patient-focused outcomes of medicines optimisation means increased engagement in pharmacotherapeutics for all healthcare professionals, including nurses

• • Despite the recommendations aimed at promoting medicines optimisation, medicines-related harm persists among patients

• • Potential strategies for reducing medicines-related harm include monitoring patients, structured multidisciplinary working, patient involvement and promoting a nurse-led approach

Medicines optimisation

Medicines optimisation is a multidisciplinary and patient-focused approach to achieving optimal patient outcomes from the use of medicines. It is an extension of medicines management, which focuses on the administration of medicines rather than their effects on patients (Royal Pharmaceutical Society (RPS) 2013, NICE 2015a). Medicines optimisation involves patients being monitored for any clinical changes that may be linked to medicines, and this information being shared among the multidisciplinary team (Jordan et al 2021). This shift in emphasis from medicines management to the patient-focused outcomes of medicines optimisation means increased engagement in pharmacotherapeutics for all healthcare professionals, including nurses; for example, medicines optimisation entails taking time to monitor the effects of medicines on patients (RPS 2013).

The Nursing and Midwifery Council (NMC), the RPS and Royal College of Nursing (RCN) all expect nurses to ensure patient safety and demonstrate competence in relation to medicines use, with the NMC (2018) stating that nurses should ‘recognise and respond to adverse or abnormal reactions to medications’. This expectation reflects medicines optimisation policy documents from NHS England and NHS Improvement (2019), the Care Quality Commission (CQC) (2019), and nurses’ regulatory bodies globally, for example the Australian Nursing and Midwifery Federation (2013). However, none of these documents specify how adverse drug reactions are to be identified, or by whom.

Persistent medicines-related harm

Despite recommendations aimed at promoting medicines optimisation, medicines-related harm persists among patients. Risk minimisation measures – such as laboratory monitoring and education for patients and healthcare professionals – have not achieved their full potential (Yasuoka et al 2019). Electronic prescribing initiatives and decision support programmes have been shown to improve prescribing, but there is little evidence that they improve clinical outcomes (Monteiro et al 2019) or prevent adverse drug reactions (O’Mahony et al 2020). For example, Rieckert et al (2020) undertook a large trial that used an electronic decision support tool to reduce polypharmacy in people aged 75 years and over with chronic diseases. The researchers reported fewer hospital admissions in the intervention group but a small increase in falls and fractures compared with the control group.

Cautionary advice has been provided for prescribers in relation to various medicines, such as the recommendation by the Department of Health and Social Care to reduce the use of antipsychotics in people with dementia (Banerjee 2009). However, some medicines continue to result in persistent medicines-related harm. For example, in one study examining patients attending emergency departments, 85% of older patients who had fallen had been prescribed hypnotic medicines (Díaz-Gutiérrez et al 2018). Another study found that when being discharged from hospital, 20% of older people were prescribed at least one potentially inappropriate medicine (Parekh et al 2019), with the benefits of such medicines often outweighed by the risks of adverse drug reactions (American Geriatrics Society 2019).

Finding solutions to medicines-related harm

The WHO (2019) has suggested that medicines safety will not improve without a redesign of healthcare services and the implementation of processes that will enable healthcare professionals to manage their workloads in response to increasing prescribing levels. For example, the ongoing WHO (2017) campaign Global Patient Safety Challenge: Medication Without Harm seeks to develop systems for medicines management that would halve avoidable medicine-related harm by 2022. Both the RPS (2013) medicines optimisation guidance and the WHO’s (2017) proposed approach emphasise the importance of monitoring the effects of medicines on patients’ outcomes and experiences.

Monitoring patients for avoidable medicines-related harm

Monitoring patients is integral to medicines administration because it can enable potential medicines-related harms to be identified. For example, it is important to check the patient’s pulse before administering digoxin, since this medicine can lead to life-threatening arrhythmias (Huynh et al 2016). Nurses have a crucial role in monitoring patients for adverse drug reactions. Figure 1 shows nurses’ primary roles in medicines management and the areas where adverse drug reactions are most likely to occur (WHO 2017). These areas include high-risk situations such as acute clinical episodes, polypharmacy, and transitions in care such as when a patient moves between hospital and their home or care home.

Figure 1.

Nurses’ primary roles in medicines management and the areas where adverse drug reactions are most likely to occur

In one study of healthcare professionals including 4,888 nurses across 17 European countries, most nurses (69%) reported monitoring patients for therapeutic or adverse effects of medicines in the past month (De Baetselier et al 2020). However, in the UK there have been reports of patients being seriously harmed when well-known adverse effects of long-term medicines were not observed and reported. For example, following deaths attributed to the antipsychotic medicine clozapine, two coroners wrote to England’s secretary of state for health and social care in 2018 stating that many staff were unaware of the medicine’s potential side effects and warning signs for deterioration (Dyer 2018).

Undertaking medication reviews

Iatrogenic harm refers to harm caused inadvertently during treatment, and is usually due to systems failures rather than the culpability of individual healthcare staff (Larouzee and Le Coze 2020). One strategy for reducing adverse drug reactions is a medication review, which usually involves prescribers or pharmacists undertaking a structured evaluation of a patient’s medicines with the aim of optimising medicines use and improving health outcomes (WHO 2019). However, the form, quality and effectiveness of medication reviews vary (NICE 2015a), and they also do not require patient input (WHO 2019). In addition, despite advances in medicines management, the medicines of some patients in long-term care are only checked annually, which is the minimum requirement (NICE 2015b). Prescribers may also be reluctant to follow recommendations, citing an insufficient number of staff to monitor the effects of medicines and perceived resistance from care home staff or family members (Paque et al 2019, Disalvo et al 2020). For example, in one Finnish study of older people in care homes, deprescribing was recommended but not implemented in 50% of cases (Toivo et al 2019).

While pharmacist-led medication reviews have been shown to improve prescribing practice (Hill-Taylor et al 2016, Rankin et al 2018), one systematic review of 31 clinical trials found minimal evidence that medication reviews improved patient outcomes (Huiskes et al 2017). However, Gray et al’s (2017) meta-analysis of 13 trials involving 6,198 older patients indicated that medication reviews reduced the risk of patients experiencing adverse drug reactions.

Assessing the appropriateness of medicines

The prescribing of potentially inappropriate medicines is associated with adverse drug reactions, hospital admissions (Xing et al 2019), emergency department attendances, functional decline and deteriorating quality of life (Liew et al 2019). Examples of potentially inappropriate medicines include those that should be avoided in older people, such as the sedative zolpidem tartrate, which is not recommended in older people because of the increased risk of protracted sedation and ataxia (condition that affects coordination and balance) (American Geriatrics Society 2019).

Improved prescribing procedures do not necessarily improve patient outcomes or well-being. For example, if used alone, the approach of checking the patient’s prescriptions against a list of high-risk medicines does not take into account the patient’s clinical condition. Detailed decision tools such as the STOPP-START medication review tool (Moody et al 2017), require more extensive clinical information than that available on medicines charts and laboratory reports, for example vital signs or falls history (Carvalho et al 2019). However, such tools do not identify patient-specific signs and symptoms such as anorexia, weight changes, dehydration or suboptimal oral health, all of which can affect patients’ well-being. In addition, there is no evidence that such tools improve patients’ quality of life (Hill-Taylor et al 2016, Huiskes et al 2017).

Structured multidisciplinary working and patient involvement

Prioritising medicines optimisation is crucial to patient safety (RCN 2020). However, it has been identified that despite the publication of numerous policy documents, some nurses and doctors still consider monitoring the effects of medicines to be the role of another professional group (Jordan 2002, RPS and RCN 2019, De Baetselier et al 2020).

Multidisciplinary collaboration can result in individualised care, careful monitoring of outcomes, and increasingly frequent reviews of medicines and adherence (RPS 2013). The NHS (2021) has indicated that a structured medication review should take prescribers at least 30 minutes. A structured, multifaceted and multidisciplinary medication review would mitigate the risk of medicines-related harm, notably in community care, where the lack of patient safety interventions is most acute (WHO 2019). However, existing interventions aimed at meeting the WHO’s (2017) Global Patient Safety Challenge focus on high-risk medicines and single-profession initiatives such as laboratory monitoring (Peek et al 2020), rather than increased patient involvement in medicines optimisation and measures aimed at reducing and monitoring polypharmacy (Garfield et al 2020).

The General Medical Council (2021) advises doctors that whether they are prescribing repeat prescriptions or on a ‘one-off’ basis, they must make sure that ‘suitable arrangements are in place for monitoring, follow-up and review’, and that ‘any repeat prescription you sign is safe and appropriate’. However, the CQC (2019) reported that some patients who were prescribed high-dose antipsychotic medicines, for example, ‘were not monitored because there were no systems to support the process’ and professional responsibilities were not defined.

Promoting a nurse-led approach

The adverse drug reaction profile (ADRe) is a monitoring system that is designed to complement medication reviews (Swansea University 2021). The ADRe enables nurses or carers to collaborate with patients to check through a structured list of signs and symptoms that are related to the patient’s prescription medicines, before sharing any findings with pharmacists and prescribers. This enables any links between the patient’s signs and symptoms, and the known adverse effects of specific medicines to be identified. There are four main sections of the ADRe documentation, which prompt nurses to (Jordan et al 2021):

• • Observe the patient’s vital and physical signs.

• • Review the patient’s symptoms, medicines intake and adherence to treatment.

• • Seek to understand the patient’s perspective.

• • Review any prescribed or over-the-counter medicines, and any laboratory tests the patient has undergone.

Figure 2 describes the stages of the ADRe and its practical application.

Figure 2.

Stages of the adverse drug reaction profile (ADRe) and its practical application

By ensuring that the members of the multidisciplinary team who are involved in the patient’s medication review have access to comprehensive patient information, the ADRe assists in identifying and addressing a variety of symptoms of medicines-related harm – including pain, sedation, agitation, nausea, stiffness, breathing difficulties, dizziness and suboptimal eyesight – that are otherwise easily overlooked, particularly in patients with communication challenges (Jordan et al 2002, 2015, 2019, 2021). The results of the ADRe can also be used as a basis for discussing possible prescription changes with pharmacists and prescribers. Table 1 provides some examples of case reports where medicines-related harm was identified and resolved using the ADRe.

Table 1.

Case reports where medicines-related harm was identified and resolved using the adverse drug reaction profile (ADRe)

The time that nurses spend monitoring patients using a structured approach such as the ADRe can be regained by reduced care demands; for example, when antipsychotics are deprescribed, patients may become calmer and less aggressive (Jordan et al 2019, NHS 2021). One Belgian study showed that nurses’ enhanced involvement in monitoring for adverse drug reactions resulted in planned medicine changes for 21% of nursing home residents (Dilles et al 2013).

Medicines-related harms may present as subtle symptoms that require attention before they escalate. Structured patient monitoring enables nurses and carers to identify issues and discuss medicines optimisation measures such as deprescribing with other members of the multidisciplinary team, while ensuring that patients and carers have a ‘voice’ in any medicines-optimisation decisions. This person-centred, shared decision-making should also explore the balance between symptom relief and medicines-related harms; for example, the pain relief provided by ibuprofen should be measured against the potentially negative long-term effects on patients’ kidney function and cardiovascular health (RPS 2013).

Conclusion

Many healthcare professionals, including nurses, are often unclear about their responsibility to monitor patients for medicines-related harms. In addition, while prescribed medicines are often used to manage serious long-term conditions, their potential for harm is often not fully acknowledged. To ensure medicines optimisation, nurses should be involved in monitoring patients’ signs and symptoms using a structured checklist such as the ADRe to identify and address any medicines-related harms.

References

1. American Geriatrics Society (2019) American Geriatrics Society 2019 Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 67, 4, 674-694. doi: 10.1111/jgs.15767
   [CROSSREF] [Google Scholar]
2. Aronson JK (2012) Adverse drug reactions: history, terminology, classification, causality, frequency, preventability. In Talbot J, Aronson JK (Eds) Stephens’ Detection and Evaluation of Adverse Drug Reactions: Principles and Practice. Sixth edition. John Wiley & Sons, Chichester, 1-119.
   [Google Scholar]
3. Australian Nursing and Midwifery Federation (2013) Nursing Guidelines: Management of Medicines in Aged Care. http://anf.org.au/documents/reports/Management_of_Medicines_Guidelines_2013.pdf (Last accessed: 15 June 2021.)
   [Google Scholar]
4. Banerjee S (2009) The Use of Antipsychotic Medication for People with Dementia: Time for Action. The Stationery Office, London.
   [Google Scholar]
5. Cahir C, Wallace E, Cummins A et al (2019) Identifying adverse drug events in older community-dwelling patients. Annals of Family Medicine. 17, 2, 133-140. doi: 10.1370/afm.2359
   [CROSSREF] [Google Scholar]
6. Care Quality Commission (2019) Medicines in Health and Adult Social Care. Learning from Risks and Sharing Good Practice for Better Outcomes. http://www.cqc.org.uk/sites/default/files/20190605_medicines_in_health_and_adult_social_care_report.pdf (Last accessed: 15 June 2021.)
   [Google Scholar]
7. Carvalho R, Lavrador M, Cabral AC et al (2019) Patients’ clinical information requirements to apply the STOPP/START criteria. International Journal of Clinical Pharmacy. 41, 6, 1562-1569. doi: 10.1007/s11096-019-00920-5
   [CROSSREF] [Google Scholar]
8. De Baetselier E, Van Rompaey B, Batalha LM et al (2020) EUPRON: nurses’ practice in interprofessional pharmaceutical care in Europe. A cross-sectional survey in 17 countries. BMJ Open. 10, 6, e036269. doi: 10.1136/bmjopen-2019-036269
   [CROSSREF] [Google Scholar]
9. Díaz-Gutiérrez MJ, Martínez-Cengotitabengoa M, Bermúdez-Ampudia C et al (2018) Overdosing of benzodiazepines/Z-drugs and falls in older adults: costs for the health system. Experimental Gerontology. 110, 42-45. doi: 10.1016/j.exger.2018.05.002
   [CROSSREF] [Google Scholar]
10. Dilles T, Vander Stichele RH, Van Bortel LM et al (2013) The development and test of an intervention to improve ADR screening in nursing homes. Journal of the American Medical Directors Association. 14, 5, 379.e1-379.e6. doi: 10.1016/j.jamda.2013.02.011
    [CROSSREF] [Google Scholar]
11. Disalvo D, Luckett T, Bennett A et al (2020) Multidisciplinary perspectives on medication-related decision-making for people with advanced dementia living in long-term care: a critical incident analysis. European Journal of Clinical Pharmacology. 76, 4, 567‐578. doi: 10.1007/s00228-019-02820-z
    [CROSSREF] [Google Scholar]
12. Dyer C (2018) Coroners warn health secretary of clozapine deaths. BMJ. 363, k5421. doi: 10.1136/bmj.k5421
    [CROSSREF] [Google Scholar]
13. Edwards IR, Aronson JK (2000) Adverse drug reactions: definitions, diagnosis, and management. The Lancet. 356, 9237, 1255-1259. doi: 10.1016/S0140-6736(00)02799-9
    [CROSSREF] [Google Scholar]
14. Elliott RA, Camacho E, Campbell F et al (2018) Prevalence and Economic Burden of Medication Errors in the NHS in England. http://www.eepru.org.uk/wp-content/uploads/2020/03/medication-error-report-edited-27032020.pdf (Last accessed: 15 June 2021.)
    [Google Scholar]
15. European Union (2010) Directive 2010/84/EU of the European Parliament and of the Council of 15 December 2010. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2010:348:0074:0099:EN:PDF (Last accessed: 15 June 2021.)
    [Google Scholar]
16. Garfield S, Teo V, Chan L et al (2020) To what extent is the World Health Organization’s medication safety challenge being addressed in English hospital organizations? A descriptive study. Journal of Patient Safety. doi: 10.1097/PTS.0000000000000757
    [CROSSREF] [Google Scholar]
17. General Medical Council (2021) Good Practice in Prescribing and Managing Medicines and Devices. http://www.gmc-uk.org/-/media/ documents/prescribing-guidance- updated-english-20210405_ pdf-85260533.pdf?la=en&hash=716B06E30FA2D9CA770 0B94B3F55173B10F3058A %20accessed%2028.5.21 (Last accessed: 15 June 2021.)
    [Google Scholar]
18. Gray SL, Hart LA, Perera S et al (2017) Meta-analysis of interventions to reduce adverse drug reactions in older adults. Journal of the American Geriatrics Society. 66, 2, 282-288. doi: 10.1111/jgs.15195
    [CROSSREF] [Google Scholar]
19. Gyllensten H, Rehnberg C, Jönsson AK et al (2013) Cost of illness of patient-reported adverse drug events: a population-based cross-sectional survey. BMJ Open. 3, 6, e002574. doi: 10.1136/bmjopen-2013-002574
    [CROSSREF] [Google Scholar]
20. Hill-Taylor B, Walsh KA, Stewart S et al (2016) Effectiveness of the STOPP/START (screening tool of older persons’ potentially inappropriate prescriptions/screening tool to alert doctors to the right treatment) criteria: systematic review and meta-analysis of randomized controlled studies. Journal of Clinical Pharmacology and Therapeutics. 41, 2, 158-169. doi: 10.1111/jcpt.12372
    [CROSSREF] [Google Scholar]
21. Huiskes VJ, Burger DM, van den Ende CH et al (2017) Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials. BMC Family Practice. 18, 1, 5. doi: 10.1186/s12875-016-0577-x
    [CROSSREF] [Google Scholar]
22. Huynh N, Snyder R, Vidal JM et al (2016) Assessment of the nurse medication administration workflow process. Journal of Healthcare Engineering. 2016, 6823185. doi: 10.1155/2016/6823185
    [CROSSREF] [Google Scholar]
23. Jennings EL, Murphy KD, Gallagher P et al (2020) In-hospital adverse drug reactions in older adults; prevalence, presentation and associated drugs — a systematic review and meta-analysis. Age and Ageing, 49, 6, 948-958. doi: 10.1093/ageing/afaa188
    [CROSSREF] [Google Scholar]
24. Jones R, Moyle C, Jordan S (2016) Nurse-led medicines monitoring: a study examining the effects of the West Wales Adverse Drug Reaction Profile. Nursing Standard. 31, 14, 42-53. doi: 10.7748/ns.2016.e10447
    [CROSSREF] [Google Scholar]
25. Jordan S (2002) Managing adverse drug reactions: an orphan task. JAN. 38, 5, 437-448. doi: 10.1046/j.1365-2648.2002.02205.x
    [CROSSREF] [Google Scholar]
26. Jordan S, Tunnicliffe C, Sykes A (2002) Minimizing side‐effects: the clinical impact of nurse‐administered ‘side‐effect’ checklists. JAN. 37, 2, 155-165. doi: 10.1046/j.1365-2648.2002.02064.x
    [CROSSREF] [Google Scholar]
27. Jordan S, Banner T, Gabe-Walters M et al (2019) Nurse-led medicines’ monitoring in care homes, implementing the Adverse Drug Reaction (ADRe) Profile improvement initiative for mental health medicines: an observational and interview study. PLoS One. 14, 9, e0220885. doi: 10.1371/journal.pone.0220885
    [CROSSREF] [Google Scholar]
28. Jordan S, Gabe-Walters ME, Watkins A et al (2015) Nurse-led medicines’ monitoring for patients with dementia in care homes: a pragmatic cohort stepped wedge cluster randomised trial. PLoS One. 10, 10, e0140203. doi: 10.1371/journal.pone.0140203
    [CROSSREF] [Google Scholar]
29. Jordan S, Prout H, Carter N et al (2021) Nobody ever questions – polypharmacy in care homes: a mixed methods evaluation of a multidisciplinary medicines optimisation initiative. PLoS One. 16, 1, e0244519. doi: 10.1371/journal.pone.0244519
    [CROSSREF] [Google Scholar]
30. Larouzee J, Le Coze JC (2020) Good and bad reasons: the Swiss cheese model and its critics. Safety Science. 126, 104660. doi: 10.1016/j.ssci.2020.104660
    [CROSSREF] [Google Scholar]
31. Liew TM, Lee CS, Goh-Shawn KL et al (2019) Potentially inappropriate prescribing among older persons: a meta-analysis of observational studies. Annals of Family Medicine. 17, 3, 257-266. doi: 10.1370/afm.2373
    [CROSSREF] [Google Scholar]
32. Monteiro L, Maricoto T, Solha I et al (2019) Reducing potentially inappropriate prescriptions for older patients using computerized decision support tools: systematic review. Journal of Medical Internet Research. 21, 11, e15385. doi: 10.2196/15385
    [CROSSREF] [Google Scholar]
33. Moody D, Lyndon H, Stevens G (2017) Toolkit for General Practice in Supporting Older People Living with Frailty. http://www.england.nhs.uk/wp-content/uploads/2017/03/toolkit-general-practice-frailty-1.pdf (Last accessed: 15 June 2021.)
    [Google Scholar]
34. National Institute for Health and Care Excellence (2015a) Medicines Optimisation: The Safe and Effective Use of Medicines to Enable the Best Possible Outcomes. NICE guideline No. 5. NICE, London.
    [Google Scholar]
35. National Institute for Health and Care Excellence (2015b) Medicines Management in Care Homes. Quality standard No. 85. NICE, London.
    [Google Scholar]
36. NHS (2021) Network Contract Directed Enhanced Service. Structured Medication Reviews and Medicines Optimisation: Guidance. http://www.england.nhs.uk/wp-content/uploads/2021/03/B0431-network-contract-des-smr-and-mo-guidance-21-22.pdf (Last accessed: 15 June 2021.)
    [Google Scholar]
37. NHS England, NHS Improvement (2019) The NHS Patient Safety Strategy: Safer Culture, Safer Systems, Safer Patients. http://www.england.nhs.uk/wp-content/uploads/2020/08/190708_Patient_Safety_Strategy_for_website_v4.pdf (Last accessed: 15 June 2021.)
    [Google Scholar]
38. NHS Business Services Authority (2020) Prescription Cost Analysis: England 2019. http://nhsbsa-opendata.s3.eu-west-2.amazonaws.com/PCA_Statistical_Summary_Narrative_2019_v002.html (Last accessed: 15 June 2021.)
    [Google Scholar]
39. Nursing and Midwifery Council (2018) Future Nurse: Standards of Proficiency for Registered Nurses. NMC, London.
    [Google Scholar]
40. O’Mahony D, Gudmundsson A, Soiza RL et al (2020) Prevention of adverse drug reactions in hospitalized older patients with multi-morbidity and polypharmacy: the SENATOR* randomized controlled clinical trial. Age and Ageing. 49, 4, 605-614. doi: 10.1093/ageing/afaa072
    [CROSSREF] [Google Scholar]
41. Oscanoa TJ, Lizaraso F, Carvajal A (2017) Hospital admissions due to adverse drug reactions in the elderly. A meta-analysis. European Journal of Clinical Pharmacology. 73, 6, 759-770. doi: 10.1007/s00228-017-2225-3
    [CROSSREF] [Google Scholar]
42. Panagioti M, Khan K, Keers RN et al (2019) Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 366, l4185. doi: 10.1136/bmj.l4185
    [CROSSREF] [Google Scholar]
43. Paque K, Vander Stichele R, Elseviers M et al (2019) Barriers and enablers to deprescribing in people with a life-limiting disease: a systematic review. Palliative Medicine. 33, 1, 37-48. doi: 10.1177/0269216318801124
    [CROSSREF] [Google Scholar]
44. Parekh N, Ali K, Davies JG et al (2019) Do the 2015 Beers Criteria predict medication-related harm in older adults? Analysis from a multicentre prospective study in the United Kingdom. Pharmacoepidemiology and Drug Safety. 28, 11, 1464-1469. doi: 10.1002/pds.4849
    [CROSSREF] [Google Scholar]
45. Payne RA, Abel GA, Guthrie B et al (2013) The effect of physical multimorbidity, mental health conditions and socioeconomic deprivation on unplanned admissions to hospital: a retrospective cohort study. Canadian Medical Association Journal. 185, 5, E221-E228. doi: 10.1503/cmaj.121349
    [CROSSREF] [Google Scholar]
46. Peek N, Gude WT, Keers RN et al (2020) Evaluation of a pharmacist-led actionable audit and feedback intervention for improving medication safety in UK primary care: an interrupted time series analysis. PLoS Medicine. 17, 10, e1003286. doi: 10.1371/ journal.pmed.1003286
    [CROSSREF] [Google Scholar]
47. Rankin A, Cadogan CA, Patterson SM et al (2018) Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews. Issue 9. CD008165. doi: 10.1002/14651858.CD008165.pub4
    [CROSSREF] [Google Scholar]
48. Rieckert A, Reeves D, Altiner A et al (2020) Use of an electronic decision support tool to reduce polypharmacy in elderly people with chronic diseases: cluster randomised controlled trial. BMJ. 369, m1822. doi: 10.1136/bmj.m1822
    [CROSSREF] [Google Scholar]
49. Royal College of Nursing (2020) Medicines Management. http://www.rcn.org.uk/professional-development/publications/pub-009018 (Last accessed: 15 June 2021.)
    [Google Scholar]
50. Royal Pharmaceutical Society (2013) Medicines Optimisation: Helping Patients to Make the Most of Medicines. Good Practice Guidance for Healthcare Professionals in England. http://www.nhs.uk/about-the-nhs-website/professionals/healthandcareprofessionals/your-pages/documents/rps-medicines-optimisation.pdf (Last accessed: 15 June 2021.)
    [Google Scholar]
51. Royal Pharmaceutical Society, Royal College of Nursing (2019) Professional Guidance on the Administration of Medicines in Healthcare Settings. RPS and RCN, London.
    [Google Scholar]
52. Sakiris MA, Sawan M, Hilmer SN et al (2021) Prevalence of adverse drug events and adverse drug reactions in hospital among older patients with dementia: a systematic review. British Journal of Clinical Pharmacology. 87, 2, 375-385. doi: 10.1111/bcp.14417
    [CROSSREF] [Google Scholar]
53. Swansea University (2021) ADRe – The Adverse Drug Reaction Profile: Helping to Monitor Medicines. http://www.swansea.ac.uk/adre (Last accessed: 15 June 2021.)
    [Google Scholar]
54. Toivo T, Airaksinen M, Dimitrow M et al (2019) Enhanced coordination of care to reduce medication risks in older home care clients in primary care: a randomized controlled trial. BMC Geriatrics. 19, 332. doi: 10.1186/s12877-019-1353-2
    [CROSSREF] [Google Scholar]
55. World Health Organization (2017) Medication Without Harm: WHO Global Patient Safety Challenge. http://apps.who.int/iris/handle/10665/255263 (Last accessed: 15 June 2021.)
    [Google Scholar]
56. World Health Organization (2019) Medication Safety in Polypharmacy. http://apps.who.int/iris/bitstream/handle/10665/325454/WHO-UHC-SDS-2019.11-eng.pdf?sequence=1&isAllowed=y (Last accessed: 15 June 2021.)
    [Google Scholar]
57. Xing XX, Zhu C, Liang HY et al (2019) Associations between potentially inappropriate medications and adverse health outcomes in the elderly: a systematic review and meta-analysis. Annals of Pharmacotherapy. 53, 10, 1005-1019. doi: 10.1177/1060028019853069
    [CROSSREF] [Google Scholar]
58. Yasuoka Y, Kaneko M, Narukawa M (2019) Evaluation of the implementation of additional risk minimization activities in Europe, the USA, and Japan. Pharmaceutical Medicine, 33, 5, 417-424. doi: 10.1007/s40290-019-00303-1
    [CROSSREF] [Google Scholar]