200 CHAPTER 3.1 Methods Intervention arm The STRIP intervention as in OPERAM • Step 1. Structured History-taking of Medication (SHiM) In order to optimise patients’ pharmacotherapy during their hospital stay, their medication lists have to be as accurate as possible at the point of arrival. Several studies have shown that older patients’ medication lists on admission to hospital significantly differ from what they actually take at home [26–29]. These differences can be of clinical significance, causing adverse drug events (ADEs) or patient harm [30, 31] and older patients are particularly at risk from these events [32]. Medicines reconciliation as an intervention has repeatedly been shown to reduce medication discrepancies and to improve the accuracy of medication lists [26, 29], although there is no clear consensus on the most accurate method of carrying out medicines’ reconciliation. Different sources for obtaining information on medication history include letters from referring physicians, community pharmacy dispensing lists and patients’ own medications, although none of these methods is completely accurate when taken in isolation and the use of several sources is recommended [31]. To address this problem, the Structured History-taking of Medication (SHiM) was devised by Spee and colleagues [33] who developed a 21-item questionnaire that can be used to fully interrogate a patient’s current medication use (including non-prescription medications), patient’s attitudes and beliefs towards their own medication regime, any perceived barriers to medication use as well as any known medication allergies or intolerances [28]. Application of the SHiM has been shown to successfully detect discrepancies in medication lists in up to 92% of patients being admitted to hospital, reducing potential patient harm as a result of addressing these errors [28, 34]. In OPERAM, a SHiM assessment is conducted for all intervention patients, either with the patients themselves or their next-of-kin in the case of patients with cognitive impairment, typically between 24 and 72h after inclusion in the trial. It is completed by a trained researcher (pharmacist, physician or nurse) and is performed separately to the routine clinical history-taking which is completed on admission by a member of the attending medical team. In OPERAM, a modified version of the SHiM is used, which has removed the final 7 questions from previously described versions [28] (see Table 1). In addition to the SHiM, at least one other source is consulted. Preferably, a complete medication dispensing list is obtained from the community pharmacy and/or the general practitioner (GP), or if not available, a list of medications on admission is taken from the patient’s medical records or from the primary care physician’s referral letter.
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