No pharmacist will be actively involved in the medication review, counseling or discharge and post-discharge procedure. In both groups the best possible preadmission drug list will be compiled for inpatients within 72 hours after admission to the geriatric ward. If potentially dangerous or life-threatening drug errors are observed in the usual care group, this will be communicated to the treating physician

The clinical pharmacist-collaborative service in the intervention group comprises six steps based on the clinical pharmacy intervention proposal of Van der Linden et al (Drugs Aging 2020).

The first three steps focus on optimizing the drug therapy of geriatric inpatients. The remaining steps target a safe transition from the hospital to the community.

1. Assessing patient and caregiver preferences
2. Medication reconciliation on admission
3. Performing a comprehensive medication review before discharge
4. Promoting safe transition

4.a. Compiling a patient friendly medication list

4.b.Optimizing communication with healthcare providers in primary care:

4.b.i.Providing a copy of the medication list for the community pharmacist

4.b.ii. Contacting the general practitioner by phone

4.b.iii. Contacting, if applicable the home care nurse or the nurse from the nursing home by phone.

5.A motivation interview will take place before discharge with patients and caregivers

6.Post-discharge follow-up: 6.a.Follow-up call to discuss potential drug therapy issues, therapy adherence and to resolve any pending issues 6.b.A telepharmacology service will be provided to primary healthcare professionals as a means to consult the ward-based clinical pharmacists and/or research team after discharge.

An unplanned hospital visit is defined as an unplanned hospital admission or an emergency department visit

Number of general practitioners contacts

Death date