Retirement and nursing homes undesired adverse event was the reason for the recommendation. 72% of the recommendations gave way to an adjustment of the medication. Discontinuation and reduction of medication The most frequent recommendation (43%) was for the discontinuation of medication, followed by adjustment trough reducing the dose in 23% of the cases. The effects of GEMED were clear in the example of an 83-year old woman: she came to the home with coordination problems and mixed dementia, was confused, sometimes aggressive, dizzy, tired during the day and suffered from hallucinations. During the course of the analysis, two medicines were discontinued and the dose of other medication halved or reduced. After just two months, she was far more alert, recognised trusted persons and was much more cooperative. 37 Medication process improved During the course of the GEMED project, the entire medication process in the participating homes was also evaluated using checklists. This helped to identify medication errors (e.g. taken at the wrong time, wrong dose, duration of time to take medication was too long) and mistakes in storage. According to the Chamber of Pharmacists, the documentation called for improvement in most cases. Observations of the NPM The NPM also highlighted errors in the medication process in 2019, particularly in the storage, distribution and use of medication. A home in Styria, for example, failed to observe that only medication given through a tube may be ground and administered through a PEG tube. Sustainedrelease medication forms and film-coated tablets with enteric coating should, on the other hand, never be ground. The commission also pointed out the ban on storing analgesics in the addictive medication cupboard. Time and again, a lack of documentation and communication resulted in errors. In a home in Lower Austria, there was criticism that the prescribed dispensing of addictive medication per person and medication was not documented in an addictive medication book. Consumption could therefore not be verified by the commission. There was no stocktake in the home either. In a nursing home in Burgenland, the commission criticised medical prescriptions, as they were barely legible. NPM recommends pharmaceutical consultations On visits in 2019, commissions recommended several times evaluating the medication or holding pharmaceutical consultations. In most cases, a step-bystep examination of prescriptions then ensued. In accordance with the quality assurance guidelines of the Austrian Chamber of Pharmacists, “Care of the residents in retirement and nursing homes or other care facilities – QSSL” (“Versorgung und Betreuung der Bewohner von Alten- und Pflegeheimen oder sonstigen Betreuungseinrichtungen – QSSL”), pharmacists should also be consulted and consideration given to interactions, double prescriptions, dosage, administering medication at the correct time and any problems in using the medication. This is common practice in a Styrian geriatric home: the