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Partnerships for Older People Project

Domiciliary Medicine Use Review by Medicines Management and
Pharmacy Team, July 2007-Mar 2008

October 2008

Cathal Doyle, RDC ([email protected])
& Bola Sotubo, Medicines Management and Pharmacy Team, Southwark Health &
Social Care


1. Introduction
This report analyses the data collated from the Domiciliary Medicine Use Review
conducted by the Medicines Management and Pharmacy Team as part of
Southwark’s Partnership for Older People’s Project (POPP).
The Medicines Management and Pharmacy Team’s objectives in the POPP project
were:
• To support and ensure patients are able to use their medicines effectively and
• To improve patient, carer and care workers involvement with medicines use • To have a consistent point of referral to suitably trained pharmacists (e.g. MUR accredited Community Pharmacists (CP) or Specialist Pharmacists) to identify older peoples’ medicine management needs and enable safe and appropriate use of medicines • To ensure collaborative working with other health and social care professionals in the community and acute trusts so that older people receive coordinated care in their homes or when moving between different care settings.
The purpose of this review is to explore older people’s experiences of managing their
medicines in the community and to help improve medicines management &
pharmacy support to enable vulnerable older people to use their medicines
appropriately and safely. It attempts to assess older people’s capacity to manage
their medicines, identify possible barriers to self-administration and assess how
people overcome these barriers. In addition to collecting data, the pharmacists
conducting the reviews provided support and solutions in collaboration with other
health and social care professionals and organisations for problems identified. These
actions were also recorded and are analysed in this report.
The Medicines Management and Pharmacy Team worked with the Southwark
POPPs evaluator to design a new tool to conduct this review. Existing Medication
Review and Medicines Use Review (MUR) templates used by GPs and CPs were
considered inadequate for this purpose. This tool is attached below as Appendix 2.

Patient selection

The reviews were conducted between July 2007 and March 2008 by three primary
care pharmacists. Data were collected from 48 patients. Referrals came mostly from
GP practices, the monthly POPP Multidisciplinary Meetings (MDMs) and the
Community Consultant Geriatrician. The average age of patients reviewed was 79.
The criteria for selection were that they are over 65 and living independently at home.
The time taken to complete the MUR was recorded in 21 of the 49 cases. The
average time recorded for these 21 cases was 44 minutes. However, this is unlikely
to include the travelling time to and from the patient’s home in all cases.
2. Adverse Drug Reactions
Patients were assessed for adverse reactions from the drugs they are using. In 85%
of cases no known Adverse Drug Reactions (ADR) were recorded. Table 1 shows
those reactions recorded. (Some patients recorded more than one ADR). Known
drug allergies are recorded in Table 2.
Table 1: Adverse Drug Reactions
None known
Dizziness, Falls, resulting in hospital admission
Table 2: Known allergies/sensitivities
No known drug allergies
Penicillin 2 Amitriptylline/simvastation 1 Cefuroxime and metronidazole
3. Medical History Issues
Patients’ medical history was identified from discussions with the patients, types of
medication seen in the home and District Nurse’s or Community Matron’s records. A
total of 181 medical history issues were recorded, an average of 3.7 per patient. (The
form has the capacity to record up to 7 medical history issues per patient.) Table 3
shows the most commonly recorded issues and the percentage of patients
experiencing them. A full list of conditions is supplied in Appendix 1.

Table 3: Most common medical history issues

Number % of patients with
Medical History Issue
recorded issue

4. Details on medication

Number of medications prescribed
A total of 407 prescribed medicines, an average of 8.3 per patient, were recorded.
Chart 1 shows a breakdown of the numbers of medicine per patient with 36% on
between 6 and 10 medications and a further 28% on between 11 and 15.
Chart 1: Breakdown of number of medicines per patient

In addition a total of 19 non-prescribed medicines were being taken by patients.
Prescribed medicines not taken
The MUR recorded a total of 18 prescribed medicines, or 4%, that were not being
taken by the patient.
Medicines taken away
Medicines were taken away from 11 patients, or 22% of the total patients reviewed.
In total, 80 medicines were taken away. However, it is important to note that 44 of
these medicines were taken from one patient.
Precise details of medicines taken away were recorded for eight patients. Table 4
lists these.
Table 4: Medicines taken away as a result of MUR
Aspirin 75mg tablets
Clopidogrel 75mg & Dexiibuptofen tablets
Dypirridamol capsules 200mg x120
Gabapentin caps 300mgx212,Fybogel
orange Sachets x20, Simvastatin 40mg
x35, Alfacalcidol 1mcg x24
Haloperidol 500mcg caps (x20)
Indapamide 2.5mg tablets, paracetamol
tabs, Co-fluampicillin caps, Co-proxamol
tabs
Flixotide Inhaler
The cost of medicines taken away was recorded for 6 of these patients. The cost
ranged from 75p to £86. The small number recorded makes a cost effectiveness
analysis unreliable for this review.
5. The administration of medicine
In 41% of cases, medicines are self-administered and in a further 9% they are self-
administered with the help of a family member. In 13% of cases an agency carer is
involved in administration. Table 5 provides a full breakdown.

Table 5: Who administers medicines
Self-administered 19

Where a family member was involved in administration, the MUR explored the type of
help provided. These are laid out in Table 6.
Table 6: Type of help given by family members
Prompts

The MUR asked a question exploring the type of agency carer involvement in
administration. Out of the seven cases where these details are recorded, the agency
carer administers the medicine in four cases and leaves the medicine out for the
patient to take themselves in three cases.


Barriers to self-administration
The MUR explored the extent and the different types of barriers to self-administration
of medicines among patients. Table 7 shows that 65% of patients had some type of
barrier to self-administration. 42% had cognitive barriers, 10% had sensory barriers
and 38% had physical barriers.

Table 7: Types of barriers to self-administration
Barriers to self-administration

Are there cognitive barriers to self-administration? Are there sensory barriers to self-administration? Are there physical barriers to self-administration?
Table 8 breaks down the cognitive barriers recorded in the MUR, with the majority
relating to confusion or forgetfulness. Table 9 breaks down the physical barriers.
Table 8: Types of cognitive barriers to self-administration
Confusion or forgetfulness
Alzheimer's 3 Dementia 1 Lack of motivation Stroke 1
Table 9: Types of physical barriers to self-administration
Housebound due to poor mobility & co-morbidities. Unable to perform routine daily activities
All five of the sensory barriers recorded were eyesight-related with some saying they
have difficulty reading small print.
The MUR measured whether there were other barriers to self-administration not
picked up in the above three categories. These are laid out in Table 10.
Table 10: Other barriers to self-administration
Doesn't understand medication
Motivation to take medicines has increased Patient can't always match medicine name to condition 1 Patient needs constant supervision in all areas of care The type of Multiple Compartment Aid (MCA) used to administer medicines was
recorded in 33 cases. As Table 11 shows, the most popular mode was blister packs
supplied by community pharmacists. These aids are non-NHS funded. Some of other
aids were provided by the PCT through District Nurses and some were purchased
and filled by patients.
Table 11: Multiple Compartment Aid used to administer medicine

Type of MCA
Number Percentage
Medicates from original packs (manufacturers) Original containers (pharmacy containers)
The MUR form asks who fills these MCAs. In all 21 cases where the answer was
recorded, the MCA is filled by the community pharmacist.
6. Medicine Use Issues
In addition to filling in the headline data analysed above, the reviewers explored in
more depth patients’ use of medicines and identified the nature of barriers to self-
administration and what was done to address them. The answers they provided were
recorded in free text. This section of the report analyses this text to show the different
types of issues encountered, the actions planned to address these issues and, where
recorded, the outcomes of actions taken.
Asked to rank whether the priority for addressing these issues were high, medium or
low, 41 (51%) of the 80 issues recorded were classed as high priority.
The issues identified were varied but the analysis identified three recurring themes as
follows:
Difficulty using medicines due to cognitive, physical or sensory barriers
The analysis is organised under these three themes.
6.1 Inappropriate use of medicines
There were several cases where the reviewer believed the existing use of medicines
was inappropriate.

Inadequate pain control (9 cases)
The most common concern identified was perceived inadequate pain control, which
was experienced by 20% of patients. In some cases the reviewer helped to resolve
these issues by discussing and agreeing changes with the patient and their GP and
counselling the patients on the appropriate and safe use of analgesics and potential
side effects.
In one case the reviewer counselled the patient on safely increasing their painkillers
from four to eight per day and how to deal with side effects. In another case
increased doses of dihydrocodeine with paracetomol were agreed. Another patient taking co-dydramol for pain that was inadequately controlled had the dosing and the timing of the medication changed and was counselled on bowel management as a result of increased dose. Another patient complained of constant mild pain but had ran out of analgesia and said that Cocodamol makes her drowsy and confused. The reviewer discussed this with the GP who agreed to prescribe paracetamol. In another case the reviewer provided advice on pain management to a patient with ulcers (pain-free at the moment) about pain management in the future. In other cases, the reviewer’s attempts to address pain control were less successful. One patient was experiencing pain when being transferred to a commode but the reviewer’s recommendations to increase paracetamol intake to four times a day was not welcomed by the patient. Another taking co-dydramol was discovered to be receiving only two doses at night, leaving her without pain relief most of the day. The reviewer attempted to discuss pain relief but this was difficult as the patient’s husband felt this would be contrary to doctors’ instructions. The reviewer referred the patient and spouse to a pain clinic. Another patient complained that ibuprofen was not providing adequate pain relief. The reviewer informed the patient’s GP who promised to review the case but felt that the patient was already on enough pain relief The time of administration inappropriate (1 case) A patient complaining of gastric acid was taking medicine (lansoprazole) at the wrong time of the day. This was changed to later in the day to ensure effective relief at times when the symptoms were worse and was advised to take an additional medicine (gaviscon) if the symptoms continued. Concerns over potential side effects (6 cases) Possible side effects of medicines were discovered for a number of patients. In one case the use of oxygen caused a very dry nose for a patient. Sodium Chloride nasal drops were suggested by the reviewer as an alternative and a referral to a respiratory nurse was made. This resulted in the prescription of a facemask and humidifier through the GP. Another patient complained of dry, irritated eyes. The reviewer suspected Hydroxycholoroquine may be causing ocular toxicity for this patient and the GP was informed in order to review the patient’s need for an eye test. In another case, Simvastatin was thought to be causing hot flushes and insomnia and the patient decided to take this medicine earlier in the evening following the advice of the reviewer. In another three cases, concerns on side effects were raised but the outcome was not recorded in the review form. A patient reported an allergy to one of two medicines and the reviewer arranged to speak to the patient’s daughter to investigate further. Another patient was discovered to have increased urinary frequency possibly as a result of bumetanide tablets, a diuretic. The reviewer planned to explore the possible reduction of bumetanide with GP and a social work assessment for a commode. Another reviewer had concerns over the drug Piroxicam used by a patient, which has reports of increased risk of skin reactions. The reviewer referred the patient to their GP for a medication review. Lack of clarity on what medicines to use (2 cases)
In some cases the reviewer discovered confusion as to what medicines were in use.
In one case, the reviewer discovered that Donepezil was increased from 5mg to
10mg by the patient’s hospital consultant but written instructions were not provided
as required for District nurses to administer the new dose. The reviewer advised the
patient’s daughter to contact the patient’s clinic to fax through instructions to the GP
and nurse. In another case a patient with swollen ankles stated that their “water
tablet” was no longer making her go to toilet but the reviewer noted there was no
such medication in the blister pack. This was discussed with the GP.
Lack of understanding on purpose of medicines (4 cases)
Some patients showed a poor understanding of the purpose of their medication. One
patient did not understand why his dose of statin was increased (from 20mg of
atorvastatin to 40mg of simvastatin.). The reviewer explained that different drugs
have different potencies and absorption rates and that both of these doses had about
the same effect. The patient was satisfied with this explanation. Another showed a
lack of understanding regarding warfarin therapy and the reviewer counselled the
patient and spouse to increase their understanding.
Fear of taking medicine (2 cases)
Some patients were fearful of taking their prescribed medicines. One patient was
unwilling to take enalapril due to fears of over-medication. The patient’s sister was on
multiple medications and became very unwell. The reviewer discussed these fears
and reassured her of the drug’s safety. Another patient was prescribed haloperidol
for nausea but was not taking it as the accompanying leaflet refers to it being an
'antipsychotic'. The reviewer counselled the patient that haloperidol can be used
safely for nausea, but usually in severe cases. Alternatives were discussed with the
patient and GP and metoclopramide was prescribed instead.

Medicine prescribed suspected inappropriate for patient’s needs (5 cases)
In some cases, the medicines prescribed were suspected by the reviewer to be
inappropriate for patients. One patient was taking a drug (Clopidogrel, with potential
side effects of gastric ulcers and bleeding) for nine months, which should have been
stopped after one month. The reviewer discussed this with the GP and the medicine
was stopped and Paracetamol prescribed. The patient’s spouse was informed and a
record of medication and times to be taken were provided in a reminder card.
Another reviewer thought that a patient taking salbutamol four times a day should
have their dose increased to six to eight times a day in order to control symptoms of
breathlessness. Another thought some of the patient’s medicines needed to be
stopped (Dypyridamole) and referred this to the GP for review. However, in these
two cases the outcome was not recorded.
In another two cases the patients’ GP responded that their patients’ medication was
appropriate. One patient’s dose of Ramipril seemed to be inappropriate to the
reviewer but the GP confirmed that it was safe to continue with this dose. Another
reviewer thought that a patient that may have required an increased use of insulin to
control high blood glucose levels in the evenings and to control neuropathy in their
feet. The GP disagreed, believing that the insulin dose was adequate.
Different methods of administration required (3 cases)
In some cases the method of administering medicine was thought to be inadequate
by the reviewer. One patient was unable to use their salbutamol easibreathe (breath
activated) inhaler due to poor inspiration. The reviewer discussed alternative devices
with the patient and GP. The GP was unsure why the patient was on salbutamol and
agreed to review whether it was required. Two patients had problems with a
medication in tablet form and as a result of the review, this was changed to liquid
form.
Inappropriate mode of dispensing (4 cases)
Some patients were discovered to be having problems using Multicompartment
Compliant Aids (MCAs) such as a dosette box. One patient had Adcal D3 chewable
tablets that were unsuitable for a dosette box. The community pharmacist was
informed and it was agreed to dispense in original containers or dispensing
container. In another case the reviewer arranged a second visit through the patient’s
GP to work with the patient and ensure it was better accepted. One patient’s son
requested that the patient’s medicines be dispensed in blister packs, following a
social worker’s advice. However, district nurses require medicines to be administered
in pharmacist dispensed and labelled containers. The reviewer agreed with the
community pharmacist, patient’s son and district nurse that medicines would be
dispensed in original packs and pharmacy containers. In another case a reviewer
was informed that a care agency’s policy is for carers to only administer medicines
from a dossete box or blister pack. This was considered poor practice by the
reviewer and the issue was discussed with the social services commissioner.
Medicines needed were not being supplied or administered (5 cases)
Medicines that should have been available according to prescriptions were found in
some cases not to be available. In two cases an inhaler needed was not included on
the repeat prescription and the reviewer contacted the patients’ GPs in both cases to
rectify this. One patient was discovered to be getting an inadequate supply of
medicine on their repeat prescription (100 tablets of co-codamol instead of 224),
which led to inadequate pain control. The reviewer contacted the GP to confirm and
change quantities on repeat prescription. In another case eye drops that should have
been administered by a district nurse in the evening were being missed. The
reviewer recommended and agreed with the patient’s daughter to purchase an
autodrop device for easy self-administration.
Further treatment thought to be needed (4 cases)
In some cases the reviewer thought that additional medicines might be needed. One
patient had wheezing and breathing difficulties and difficulty bringing up phlegm. The
reviewer arranged with the patient’s GP to prescribe sodium chloride nebulising
solution for relief (in addition to the current prescription for carbocysteine). Another
patient’s blood pressure was found to be very varied over a 3 month period and the
reviewer informed the patient’s GP, who agreed to review it. One patient at high risk
of osteoporosis was identified as needing bone health medication. The patient does
not like to chew tablets so the reviewer recommended a Bisphonate and this was
communicated to the patient’s GP. In a care home another patient was discovered
not to have been seen by a GP since admission and the reviewer arranged for the
GP to review the patient and test Thyroxine levels.

Medicines previously prescribed that should have been discontinued (4 cases)
In some cases, prescription medicines that had been stopped were available to the
patient. One patient was discovered to be using prochlorperazine and flupentixol
although this hadn't been prescribed for several months. The reviewer referred this to
the patient's GP for review. For another patient a supply of folic acid tablets probably
prescribed whilst on methotrexate was found and presumed was no longer needed.
In another case the reviewer recognised that quantities of tramadol were more than
required. They were prescribed for regular use while the patient had decided to take
it only once a day when she felt she needed it. The patients medication was being
dispensed from a dossete box into a small cup by carers. Various capsules and
tablets were found daily on the floor and in the bed by care workers. Discussions with
the GP resulted in the reduction of the dose from 100mg three times daily to 100mg
daily when required for pain.

6.2 Difficulty using medicines due to cognitive, physical or sensory barriers
Forgetfulness and confusion (6 cases)
Patient confusion and forgetfulness is a common problem identified in this review.
One patient had difficulty remembering when to take their medication. The reviewer
helped the patient complete a medication information card which listed all medicines
and when to take them. Another patient who sleeps irregular hours became confused
having to adjust the times she takes medication and antibiotics. The reviewer
discussed the options for timing with the patient and stopped co-proxamol,
paracetamol and indapamide due to a duplication of therapy and potential to
overdose. Another patient was forgetting to take an important antibiotic that was not
in their dossette box. The reviewer counselled the patient and daughter on the
importance of taking the antibiotic and provided a medical information chart for them.
The patient’s daughter agreed to discuss this with the agency carers involved in
administering medicine. In another case the patient’s carer was forgetting to prompt
medication that was not in the dosette box (Adcal and analgesia). The reviewer
counselled both the patient and carer on appropriate use of medication and supplied
a medication information card that highlighted what medicines were in and out of the
blister pack. The reviewer found paracetomol and co-codanol in another patient’s
cupboards home, taken for occasional relief of pain. The patient said co-codanol
helped relieve pain more without dizziness and the paracetomol was ineffective. The
reviewer removed the paracetomol given the confused and forgetful nature of the
patient.
Physical barriers (3 cases)
One patient was discovered to have poor Inhaler technique due to the limited use of
their left arm. The reviewer arranged for the use of an aerochamber and mask with
the community matron and their GP. Another patient was unable to press down on
their inhaler canister and also had a poor understanding of how inhalers worked.
The reviewer counselled the patient and arranged with the GP and community
pharmacist to supply a breath-activated inhaler. One patient was unable to access
medicines in child proof containers so the reviewer arranged with the patient’s
community pharmacist to use ordinary screw caps.
Eyesight (1 case)
One patient with poor eyesight was best able to identify medication through the
colour of packaging. The reviewer agreed with the community pharmacist to supply
medication from the same manufacturer to ensure consistent colours.


6.3. Delivery of dispensed medicines (8 cases)
Mobility problems prevent many patients from collecting their prescriptions and
dispensed medication from GP surgery and pharmacy
Many people have friends or family who collect medicines for them. In some cases
this works well. For example one patient with mobility problems whose friend collects
for her was informed by the reviewer of a delivery service if problems are
encountered in the future. Another patient unable to collect their medicines was likely
to be going to a care home and the niece was happy to pick up medicines in the
meantime.
However, for some cases encountered in the review, arrangements were not
satisfactory. In one case arrangements to have medicines delivered by a friend were
unreliable, in some cases leading to medication being missed. As the usual
community pharmacist did not provide a delivery service, the reviewer recommended
a change in the care package to include medication collection from the pharmacy.
Another patient’s niece was no longer able to help with medicine for much longer so
the reviewer again arranged for medication administration to be included in the
patient’s care package. Another patient’s spouse had difficulty collecting the patient’s
medicines due to a prosthetic leg and needed to use a taxi. The reviewer advised the
patient to discuss delivery with their community pharmacy. In another case it was
discovered nurses were unable to gain access to the home to dispense medication
and the reviewer made arrangement to contact a neighbour who had a key to gain
access. One patient had difficulty getting repeat prescriptions from their GP and
medicines from the pharmacist while another was down to one week’s supply of
medicine and anxious about running out. In both cases the reviewer facilitated a
repeat prescription collection service with the patient’s GP and community
pharmacist.
Timing of dispensing inconveniencing patients
In some cases the method of dispensing medicine was causing inconvenience to the
patient. One patient had quantities of medicines on repeat prescription resulting in
the patient’s spouse collecting medicines at several times a month. One patient
received only two weeks supply of cocodamol at a time for pain control after knee
operations but received a two-month supply of nitrazepam. The patient had to buy
additional cocodamol from the pharmacy until her next repeat prescription was due.
In both cases the reviewer contacted the GP to arrange to synchronise dispensing.
7. Conclusions
This analysis provides a profile of medicine use for a sample of older people in the
community and illustrates the nature of the problems experienced by that sample
around medicines management. This indicates that many of the issues highlighted
here are replicated across the population of older people in Southwark.
It shows that many of the problems encountered are avoidable and amenable to
relatively simple solutions that take into account the living circumstances and
available support networks of patients.
It also indicates the potential benefits of a proactive approach to medicines
management in older people with long-term conditions, especially those who are
housebound or have limited mobility.
Medicines Management & Pharmacy comments on the MUR analysis
The Medicines Management & Pharmacy team have added the following
commentary to this report.
The Medicines Management & Pharmacy team’s involvement in the Partnership for
Older People Project and the results of this MUR show that a cross-sector referral
system is needed to ensure safe and consistent medicines management and
pharmacy support to vulnerable older people.

Medicines management needs to be fully integrated into the Single Assessment
Process (SAP) and assessments for Long-term Conditions (LTC) across social and
healthcare organisations to ensure continuity, consistency, a whole systems
approach to care and to reduce duplication. It should include the establishment of a formal referral process to resolve medicines issues especially where needs are still unmet. The system should be accessible to and understood by all health and social care professionals, patients and carers. There is a need for a consistent assessment tool for use across health care and social care professionals and care providers in assessing medicines management needs and identifying appropriate referral. Providers of social care need to understand that medicines management support is an integral part of packages of care. All health and social care professionals need to understand how the community pharmacy contract has been implemented locally and how community pharmacists can support patients within the framework of the contract. Clear lines of accountability are needed for all commissioned services, whether through health or social care, with defined medicines management quality indicators for monitoring of service provision within service level agreements. Southwark Health and Social care has developed safe principles to support care workers in the safe administration of medicines to patients. About 150 care workers were trained and expected to directly administer medicines in order to reduce some of the issues highlighted above. However the pilot identified that some care agencies who had signed up to these principles were not supporting medicines administration. This issue needs to be addressed.
Appendix 1 – Full list of Medical History Issues recorded

Number patients
Medical History Issue
recorded with
Peripheral Vascular Disease - associated with pain Appendix 2 – Medicine Use Review Form

Partnership for Older People Project
Source of referral: POPP MDT Meeting GP Practice Community Geriatrician - Complex Care Hospital readmissions Lomond House Continuing Care Assessments Visit details Pharmacist conducting review Pharmacist signature Pharmacist accompanied on visit by: Social Worker District Nurse Community Matron Recording of patients’ informed consent To evaluate this MUR it is useful to see how often the patient attended A&E or was admitted to hospital, why they were admitted and how long they stayed. To do this we need the patient’s agreement to use their NHS number. Does the patient agree to let us use their NHS number? Health data Significant previous Adverse Drug
Medical History as described by patient and from information recorded in

Medical History Issue 1
Medical History Issue 2
Medical History Issue 3 Medical History Issue 4 Medical History Issue 5 Medical History Issue 6 Medical History Issue 7 Who is monitoring these health problems/health issues? Details on medication How many medicines are prescribed at beginning of review?
How many of the prescribed medicines are not being
taken?
How many non-prescribed medicines are being taken?

How many medicines were taken away by reviewer?

What medicines were taken away?

How many medicines are prescribed at end of review?
Are there any barriers preventing the patient from self-administering their medicines? Yes Yes No Are there sensory barriers to self- Yes No Are there physical barriers to self- Yes No Are there other barriers to self- Family/carer input into administration of medicine (i.e. not agency care worker) Care workers input into administration of medicine Is there a care package/paid care for the patient? Does the agency carer have input into administering medicine? If ‘Yes’ is the agency carer prompting Briefly describe how they help or administering Details of Multi Compartment Aid (MCA) (if applicable) What type of MCA is in use? Blister pack Medimax Other – please state Who fills the MCA? Solutions discussed and agreed with patient/carer What solutions to medicine issues were discussed? Medicines Use Issue
Priority
Proposed action
Action by
Outcome if known with dates
Who were solutions to barriers discussed with throughout this review? Patient and family member Were solutions discussed with agency carer? (if applicable) Yes No Are there any issues thrown up by this review not addressed by this form ? General Practitioner

Source: http://www.researchdevelopmentcentre.nhs.uk/downloads/POPP-Medicines-Management-Analysis.pdf

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