Table 1

Spheres of operation and intervention components of the CMR initiative

Intervention components (% perceived effort)	Component functions	Adaptations
Accessibility of evidence base (16.7)
Summaries for clinicians (3.7)	To provide condensed and easily accessible information from STOPP relevant to local patient populations	Written summaries of STOPP evidence and potentially inappropriate prescriptions list66 remained consistent across sites however they were adapted over time to reflect updated evidence base92
Portable aide-memoires (6.1)	To remind and prompt clinicians (particularly junior doctors/pharmacists) to look at high-risk medication and symptom presentations	Pocket-sized laminated cards were developed and this remained consistent across sites but adapted to reflect updated evidence base.92 Each site devised local processes for obtaining and distributing cards to staff
Education materials (6.9)	To increase clinician (doctor, pharmacist) knowledge, skills and confidence in conducting a comprehensive medication review	Adapted over time to reflect updated evidence base and initiative learning.64 67 93 94 Adapted between sites to fit with existing materials and courses, teaching style preferences and target audience
Process of enactment (24.6)
Patient identification (7.4)	To identify and target individuals and groups who may be at increased risk, prioritising available resources	Adapted in response to patient demographics/acuity and local resource availability and constraints. Adapted to existing local processes to flag patients for comprehensive medication review
Taking individual patient medication history (2.5)	To screen patients admitted to hospital, identifying an accurate medication list, and any indications of potential adverse drug reactions	Adaptations between sites in the method for obtaining the medication histories, for example, if clinicians could/could not access electronic primary care records that included regular medications
Conducting a CMR (9.3)	To perform a structured critical examination of all current medication with the aim of reaching an agreement with the patient about optimising treatment and minimising medicines-related problems.95 Ideally a CMR is conducted as part of a multidisciplinary team ward round	Adapted between sites to account for ward round consistency and availability of staff. Adaptation of who would conduct the review, when and how this would take place (eg, whether led by consultant geriatrician, junior doctor, pharmacists or conducted jointly) based on the interests and availability of expertise within each site
Communicate and act on review (5.4)	To act on and inform what, if any, changes are going to be made to the patient’s medicines regime. This requires good communication processes between hospital staff and patient/carer, as well as healthcare professionals from other settings	All sites recorded the review in the discharge care summaries but adaptations were made on how this was documented (eg, varying electronic systems), who was responsible for documenting, and the processes for internal communication (eg, to other care professionals)
Dependent processes (20.9)
Staff availability and timing of rotas (5.9)	To ensure the availability of appropriately qualified and trained staff to conduct the CMR	Adaptations made between sites based on patterns and structures of ward rounds (eg, to account for consultant availability and preferences, and trained pharmacy staff availability). Adaptations also addressed staffing-related issues including turnover, planned and unplanned leave, and weekend staffing
Medicines reconciliation process (2.2)	To provide clarity about medicines taken by the patient on admission	Each site had existing processes for taking patients’ medication histories. Adaptations between sites to increase reliability and availability of information for CMR (eg, definitions were developed for different levels of medicines reconciliation and work conducted to implement and improve care standards)
Documentation of review decisions (3.7)	To have a clear and structured template for documenting CMR which ensures that the correct review process is followed. This ensures clear documentation is available to other care professionals, to inform discharge summaries, and to support data collection and analysis	Adapted between sites to reflect existing systems and current structure of records (paper based or electronic) as embedded into standard documentation practices. In sites C–E, electronic patient record systems changed over time requiring further adaptations
Handover processes (1.2)	To establish clear processes and practices for handover of patient care from one clinical setting to another to ensure CMR is acted on. This requires good documentation, particularly as patients are discharged from hospital back to the community or other care settings	Adaptations made to respond to established processes and practices at each site. Adaptations used to improve local documentation processes including the accuracy and clarity of the information being shared
Documentation infrastructure (7.9)	To ensure documentation infrastructure is set up, and the authorities and permissions required to make changes, and the technological knowledge and skills required to enact them are in place	Adaptations to patient record structure depended on local differences including which individuals/boards were required to approve changes, the perceived priority compared with other organisational changes, the time and effort required to build technical understanding and relationships with those responsible for enacting the changes as well as the extent of use of electronic systems and the functionality of different systems in use
Dependent sociocultural issues (37.8)
Collaboration and communication between doctors and pharmacists (5.2)	To ensure staff engage in a multidisciplinary approach to deliver the intervention effectively. It may be necessary to improve relationships, increasing levels of trust and value of different professional opinions	Each site invested time and energy building relationships between doctors and pharmacists to facilitate collaborative working. This was adapted in each site depending on the historical relationships and practices between doctors and pharmacists, and the way trust and relationships grew and evolved over time
Staff awareness and competencies (10.1)	To increase the awareness and competence of doctors and pharmacists on the evidence base, including the need to conduct CMR, and how to conduct one well, was necessary to ensure enough trained and capable staff were available to conduct reviews	Adaptations between sites made based on scope of the initiative (whole hospital vs specific wards), existing curriculum requirements, training schedules and the need to develop new education material based on recognised needs across sites
Role expectations (4.7)	To set expectations about roles to ensure staff are aware of their role in medicines review and outline the need for skilled staff to perform the reviews, and the time required to do so	Adapted to reflect site processes, organisation, and staff availability and training. Adaptations made between sites on who would conduct and communicate the CMR. Role expectations varied across sites with particular groups holding different responsibilities for the CMR (eg, diverse staff combinations of doctors, junior doctors, pharmacists and nurses)
Review of decision-making processes (4.2)	To clarify who should conduct the review, at what point in the patient journey, and how the review would be used to inform future decisions about patient care	Adaptations were required for each site depending on which patient group was targeted, the staff involved in leading the review (eg, pharmacist or doctor), whether it occurred as part of multidisciplinary team ward round or not, and other factors, for example, length of stay of the patient in hospital
Junior doctor and junior pharmacist empowerment (13.8)	To support junior doctors and pharmacists in making appropriate decisions regarding potentially inappropriate prescriptions and empowerment to challenge senior decision-makers	Adaptations made to training programmes to support junior staff empowerment. Adaptations between sites used to determine when and how medication risks should be communicated depending on their level of severity to help empower junior staff to take actions (eg, one site invested in a local consensus building exercise)

CMR, comprehensive medication review; STOPP, Screening Tool of Older People’s Prescriptions.