Gather all medicines, confirm what’s taken and why, check safety and goals, then simplify and agree a clear plan.
Why a medication review pays off
Many people use a long list of pills that change over time. Doses drift, side effects creep in, and duplicate items sneak onto the list. A structured review puts the brakes on that slide. You verify what’s taken, match each item to a need, and reshape the plan so it serves the person, not the other way round. In clinics, this reduces errors and hospital visits. At home, it brings order, saves money, and builds confidence.
Doing a medication review at home: prep and safety
Good prep prevents missed details. Before the session, gather every bottle, blister, inhaler, patch, drop, cream, and supplement. Add a photo of labels if meeting remotely. Bring recent test results, device readings, and any care letters. Ask the person to share what matters most: pain relief, sleep, fewer bathroom trips, or keeping sharp for work. That aim guides every call you make during the session.
Table: what to assemble, where to find it, and notes
| What to check | Where to find it | Notes |
|---|---|---|
| Current medicines | Kitchen drawer, handbag, pillbox, pharmacy list | Include dose, timing, and route; mark what is not taken |
| Conditions and goals | Problem list, diary, conversation | Capture what the person wants from treatment |
| Allergies and bad reactions | Wallet card, clinic record | Note the drug, event, and date if known |
| Recent results | Lab portal, device apps, paper slips | A1C, eGFR, INR, BP log, peak flow, weight |
| Red flags | Symptoms list, caregiver input | Falls, confusion, swelling, bleeding, black stools, severe thirst |
| Adherence clues | Refill history, pill counts | Early refills, hoarding, broken blister packs, split tablets |
Step-by-step medication review process
Set the scene
Explain the aim: a safer, simpler plan that fits daily life. Ask permission to speak with family or a caregiver if that helps. Agree how decisions will be made and how follow-up will run.
Build the best list
Create a best possible medication history. Start with prescription drugs, then over-the-counter items, herbals, and vitamins. Include as-needed items. Confirm dose, timing, route, and the actual way it’s taken. Match each medicine to a clear reason. If the reason is missing, treat that as a task to resolve. Tools like the AHRQ MATCH guide outline reliable steps for gathering and checking this list during handoffs and discharge.
Reconcile differences
Compare the working list with clinic records, hospital discharge notes, and pharmacy data. Resolve conflicts: different doses, deleted items that re-appeared, or new starts that never reached the GP. If the person uses more than one prescriber, flag who owns what.
Check indication and benefit
For each medicine, ask: does it have a current reason, and is it pulling its weight? Use goals that matter to the person, not just lab targets. If benefit is thin, try a trial stop with a plan to monitor.
Check safety
Scan for dose issues in kidney or liver disease, duplicate drug classes, and tricky pairs that raise harm. Look for withdrawal risks, QT prolongation, bleeding, or low sugar. For older adults, the AGS Beers Criteria list helps spot items that carry extra risk. Mark narrow-index drugs that need tight control, such as warfarin or lithium. Review storage, technique, and devices: inhaler use, insulin pens, spacers, syringes.
Tame interactions
Look for clashes between medicines and between medicines and food or alcohol. Watch for NSAIDs with anticoagulants, ACE inhibitors paired with potassium-sparing diuretics, or macrolides with statins. Check for serotonin load, anticholinergic burden, and sedative stacking that invites falls. Adjust timing, swap the agent, or add a guard such as a PPI if benefit still outweighs risk.
Simplify the plan
Fewer daily doses boost success
Aim for once-daily where workable. Align timings with meals or routines. Remove duplicate products, merge combination pills when suitable, and stop what no longer serves a goal. Switch to blister packs or a weekly tray if manual sorting fails. Use plain language directions that match the label and the way tablets look in the box.
Reduce pill burden with intent
De-prescribing is not the same as doing nothing. It is an active plan to remove or reduce a medicine with a clear method and safety net. Pick one target at a time, explain why, agree the taper, set a review date, and list danger signs. Use tools like STOPP/START or Beers lists as prompts, not rigid rules.
Agree monitoring and follow-up
Write down what to track, when to test, and who will check in. Examples: blood pressure weekly for four weeks after a dose change; daily weights in heart failure; A1C in three months after adding a GLP-1; mood scores two weeks after an SSRI change.
Share the plan with all prescribers and the pharmacy
Give the person a copy they can carry.
How to conduct a medication review in clinic workflow
Triage and timing
Stratify by risk: recent discharge, five or more medicines, age over 65, kidney disease, insulin use, anticoagulants, opioids, or dementia. Book longer slots for high-risk cases or invite a pharmacist to join. Align review points with life events: new diagnosis, new medicine class, pregnancy, or a big change in symptoms.
Roles and teamwork
Name who does what. Nurses or pharmacists can build the list and teach technique. The prescriber sets goals and makes changes. Admin staff arrange tests and follow-up calls. Caregivers can spot early harm. A shared checklist keeps everyone in sync.
Documentation that works
Record the best possible medication history, the reconciled list, the agreed changes, and the monitoring plan. Use standard fields so the plan flows into discharge letters and referral notes. Add alerts in the record: steroid card needed, warfarin booklet supplied, methotrexate taken weekly, penicillin allergy verified.
Communication across settings
Send the updated list to the person, the local pharmacy, and each prescriber on the team the same day. During moves between wards, clinics, and home, use a standard set of fields drawn from national guidance. The clearer the handover, the fewer the errors.
High-risk medicines that deserve extra time
Anticoagulants
Confirm the reason, target range if INR-based, last check, and bleeding signs. Review diet interactions, missed doses, and sick day rules.
Diabetes treatments
Match drugs to kidney function and hypoglycaemia risk. Check technique for pens and sensors. Review foot risk, weight change, and driving needs.
Opioids and gabapentinoids
Confirm pain goals, function scores, and daily morphine equivalents. Screen for sedation, confusion, constipation, or falls. Plan tapers when goals are not met.
Psychotropics
Check effect on sleep, mood, and alertness. Watch for QT risk and anticholinergic load. Back slow tapers when long-term use no longer brings benefit.
Asthma and COPD inhalers
Assess symptom control and flare history. Check inhaler choice, spacer use, and breath technique. Align devices to reduce errors. Teach rinse and spit after steroids.
Kidney and liver checks
Many drugs need dose changes as kidney or liver function falls. Track eGFR and LFTs on a schedule that fits the medicine. Link lab reminders to the repeat script cycle.
Paperwork, safety nets, and home help
Clear instructions
People remember what they read later. Provide a single-page plan with the updated list, timings, and new steps. Use 12-14 point font and plain words. Add icons for morning, noon, and night.
Pill sorting and reminders
Pick a system that fits the person. Options: weekly trays, pharmacy blister packs, phone alarms, smart caps, or caregiver checks. Tie doses to daily habits: teeth brushing, breakfast, the evening news.
When to seek help fast
Spell out red flags that prompt a call: chest pain, breathlessness at rest, black stools, severe low sugar, swelling of lips or face, rash with fever, new confusion, or a fall with head hit.
Quality checks you can track
Run simple metrics: number of daily doses, number of medicines, percent with a full list on record, time from discharge to reconciliation, and share rate of plans sent to the pharmacy the same day. Watch falls, low sugar events, and avoidable admissions over time.
Common pitfalls and quick fixes
Only using the label list
A pharmacy printout is helpful, yet it misses herbals, samples, and items stopped months ago. Ask for a bag of everything. Lay it out, match each label to the working list, and cross off ghosts.
Chasing numbers not goals
Lab targets guide care, but they are not the whole story. A gentle A1C is fine if hypos vanish and energy returns. A blood pressure a touch higher may be acceptable if dizzy spells stop and walking improves.
Adding pills for side effects
If one drug causes ankle swelling or cough, think swap before adding more pills. Treat the cause first. A lower dose or a different class beats layer upon layer of fixes.
Abrupt stops
Some medicines bite back if stopped in one go: beta-blockers, steroids, PPIs, or duloxetine. Plan a taper, set check-ins, and give clear cues for when to pause the taper or step back up.
Poor inhaler technique
Many people never had a hands-on demo. Ask for a show-and-tell. Use a spacer when the device allows, and keep devices consistent across the plan to limit confusion.
No sick day rules
When vomiting, feverish, fasting, or dehydrated, some medicines increase risk. Teach simple rules for pausing metformin, SGLT2 inhibitors, ACE inhibitors, ARBs, and NSAIDs until eating and drinking are back to normal.
Duplicate therapies
Two statins, two SSRIs, or a loop plus a thiazide without a reason can sneak in during handoffs. Compare classes, not just brand names. Remove overlap unless there is a clear, time-limited plan.
No allergy verification
“Penicillin allergy” on a record without details blocks useful options for years. Ask about the reaction, timing, and what happened next. If the story sounds like a minor rash long ago, mark it for formal review.
Table: common de-prescribing candidates and actions
| Medicine or class | Common flags | Review actions |
|---|---|---|
| Sedating antihistamines | Falls, dry mouth, confusion | Stop or switch to non-sedating options |
| Benzodiazepines, Z-drugs | Daytime fog, falls, poor sleep quality | Plan a slow taper; add sleep hygiene |
| Long-term PPIs | No current GI risk, low iron or magnesium | Reduce dose or trial stop; rescue plan for relapse |
| NSAIDs in high risk | CKD, heart failure, anticoagulant use | Stop; switch to topical or paracetamol; add PPI only if needed |
| Anticholinergics | Constipation, dry mouth, memory issues | Switch to lower burden choices; review need |
| Sulfonylureas in elders | Hypos, irregular meals, CKD | Replace with safer agents and meter teaching |
Who should be in the room
Best results come when the person, a prescriber, and a pharmacist work side by side. Add a nurse, therapist, or caregiver when that adds context or skill. If language is a barrier, use trained interpreters. Remote video can work if labels and devices can be shown on screen.
Tools you can trust
For broad policy and team practice, the NICE guideline on medicines optimisation anchors safe review, reconciliation, and shared decisions. For handoffs and discharge, the AHRQ MATCH sets out steps that clinics can adapt. For older adults, the AGS Beers Criteria signpost drug classes that need extra caution. These tools back up clinical judgement; they never replace it.
Quick start checklist
- Confirm purpose and goals
- Build the best possible list
- Reconcile with records and handoffs
- Check indication, benefit, and safety
- Trim duplicates and start tapers with a plan
- Agree tests, timings, and who will check in
- Share the plan the same day with all parties
- Arrange the next review date and what will trigger an earlier visit
Keep the plan visible, review it at each visit, and celebrate wins: fewer side effects, simpler dosing, and steady progress toward personal goals.