Can you provide a step‑by‑step safety assessment guide for an adult patient, including demographics, medical history, medication review, focused physical exam, relevant labs/imaging, identification of high‑risk factors, and follow‑up planning?

Safety Assessment Guide for Adult Patients

Conduct a systematic safety assessment using the "Geriatric 5Ms" framework (Mind, Mobility, Medications, Matters Most, Multicomplexity) for all adult patients, with particular emphasis on those ≥65 years, as this evidence-based approach prioritizes detection of clinical deterioration and high-risk factors that directly impact morbidity and mortality. 1

Step 1: Demographics and Initial Data Collection

• Document age, sex, living situation, caregiver support, and insurance status at every encounter, as these factors influence medication management capacity and safety event risk 1, 2
• Obtain and maintain an updated medication list including all prescription drugs, over-the-counter products, herbal remedies, and supplements at every care transition (hospital admission, ICU transfer, discharge, outpatient visit) 1, 3
• Record all allergies and drug sensitivities as part of the initial assessment 1

Step 2: Mind Assessment (Cognitive and Psychological Status)

Begin with cognitive assessment, as this domain influences how all other domains are evaluated and managed. 1

Cognitive Screening

• Screen for cognitive impairment using validated tools (e.g., Mini-Mental State Examination with cutoff <24 points indicating impairment) 1
• If cognitive impairment is detected, perform initial evaluation to identify reversible causes: depression, vitamin B12 deficiency, hypothyroidism, and obtain structural neuroimaging 1
• Distinguish delirium from dementia: delirium has acute onset, fluctuating course, disordered attention and consciousness, while dementia has insidious onset and constant course 1

Psychiatric and Psychological Assessment

• Assess current and past suicidal ideation, plans, attempts (including aborted/interrupted attempts with details of context, method, damage, potential lethality, intent) 1
• Evaluate for homicidal/aggressive ideation and past aggressive behaviors (domestic violence, workplace violence, other physically/sexually aggressive acts) 1
• Screen for anxiety symptoms, panic attacks, depression, and sleep abnormalities including sleep apnea 1
• Assess impulsivity as a risk factor 1
• Document psychiatric history: past diagnoses, hospitalizations, emergency department visits, treatments (type, duration, doses), response to treatments, and adherence 1

Substance Use History

• Assess tobacco, alcohol, marijuana, cocaine, heroin, hallucinogens, and misuse of prescribed/over-the-counter medications 1
• Screen for current or recent substance use disorder or changes in substance use patterns 1

Step 3: Mobility and Fall Risk Assessment

Ask three key screening questions: (1) Have you fallen in the past year? (2) Do you have difficulty with gait or balance? (3) Do you feel unsteady when walking? 1

Functional Testing

• Perform Timed Up and Go (TUG) test: score >12 seconds indicates increased fall risk 1
• Conduct "Get Up and Go" test before discharge: patients unable to rise from bed, turn, and steadily ambulate require reassessment 1
• Assess tandem stand: inability to hold for 10 seconds warrants broader fall risk assessment 1

Fall Risk Factor Assessment (P-SCHEME)

• Pain: axial or lower extremity pain 1
• Shoes: suboptimal footwear characteristics 1
• Cognitive impairment: as assessed above 1
• Hypotension: orthostatic or iatrogenic; perform orthostatic blood pressure measurement 1
• Eyesight: vision impairment 1
• Medications: centrally acting drugs (see below) 1
• Environmental factors: home safety hazards 1

Additional Fall History Elements

• Document location and cause of fall, time spent on floor/ground, loss of consciousness/altered mental status, near-syncope, melena 1
• Assess for specific comorbidities: dementia, Parkinson's disease, stroke, diabetes, prior hip fracture, depression 1
• Evaluate neurological status: peripheral neuropathies, proximal motor strength 1
• Consider EKG, complete blood count, electrolyte panel, and appropriate imaging based on clinical presentation 1

Step 4: Comprehensive Medication Review

Review all medications at every encounter, as polypharmacy (≥5 medications) is associated with drug-drug interactions, cognitive impairment, functional decline, and death. 1

High-Risk Medication Identification

Apply validated screening tools (Beers Criteria, STOPP/START criteria) to identify potentially inappropriate medications. 1, 3

Priority High-Risk Drug Classes

• Anticoagulants (e.g., warfarin): high-priority target for adverse drug events 1
• Antidiabetic agents (e.g., insulin): risk of hypoglycemia 1
• Opioids: increased risk for respiratory depression, falls, cognitive impairment 1
• Benzodiazepines: linked to cognitive impairment, delirium, falls, fractures 1, 3
• NSAIDs: associated with gastrointestinal bleeding, acute kidney injury, heart failure exacerbation 1, 3
• Anticholinergic drugs: cause cognitive impairment 1, 3
• Antihypertensives and diuretics: risk of orthostatic hypotension and falls 1
• Psychotropic medications: associated with falls 1

Medication Safety Assessment

• Evaluate for prescribing cascade: determine if new symptoms represent adverse drug events rather than new conditions 1
• Screen for drug-drug interactions and drug-disease interactions using interaction screening tools 1
• Assess renal function: declining kidney function prolongs drug elimination and increases toxicity risk 2
• Review medication adherence and identify barriers 1
• Evaluate cognitive capacity for medication self-management: if impaired, arrange supervised administration 2

Deprescribing Considerations

• Prioritize removal of medications with unfavorable benefit-risk ratios (NSAIDs, benzodiazepines) and those causing prescribing cascades 3
• Discontinue preventive medications when estimated life expectancy is shorter than the drug's time-to-benefit 3
• Simplify dosing regimens to once or twice daily to improve adherence 3, 2

Step 5: Medical History and Physical Examination

Medical History

• Document all current and past medical illnesses, related hospitalizations, surgeries, procedures, complementary/alternative treatments 1
• Assess for neurological or neurocognitive disorders, physical trauma including head injuries 1
• Obtain sexual and reproductive history 1
• Evaluate cardiopulmonary status, endocrinological disease, infectious diseases (HIV, hepatitis C, tuberculosis, sexually transmitted diseases, locally endemic infections like Lyme disease) 1
• Assess conditions associated with significant pain and discomfort 1
• Verify ongoing relationship with primary care provider 1

Focused Physical Examination

Use the primary survey approach (Airway, Breathing, Circulation, Disability) as the first element of assessment, as data are collected according to clinical importance and align with rapid response system activation criteria. 4

• Airway: assess patency and risk of obstruction 4
• Breathing: evaluate respiratory rate, effort, oxygen saturation 4
• Circulation: assess heart rate, blood pressure (including orthostatic measurements), perfusion 4
• Disability: evaluate level of consciousness, neurological deficits 4
• Complete head-to-toe evaluation for ALL patients, including those with seemingly isolated injuries 1

Step 6: Family History

• For patients with current suicidal ideation, assess family history of suicidal behaviors in biological relatives 1
• For patients with aggressive ideation, assess family history of violent behaviors in biological relatives 1

Step 7: Personal and Social History

Psychosocial Stressors

• Assess for financial problems, housing instability, legal issues, school/occupational problems, interpersonal/relationship difficulties, lack of social support 1
• Evaluate for painful, disfiguring, or terminal medical illness 1

Trauma and Violence Exposure

• Review trauma history comprehensively 1
• Assess exposure to violence or aggressive behavior, including combat exposure and childhood abuse 1
• Document legal or disciplinary issues 1

Step 8: What Matters Most (Goals of Care)

Identify what matters most to the patient through dialogue about values, goals, and preferences, as this provides the foundation for medical decision-making. 1

Advance Care Planning

• Explore patient's readiness for advance care planning and identify barriers 1
• Identify surrogate decision-maker if patient lacks capacity 1
• Discuss values, goals, and preferences for future medical care 1
• Ensure care aligns with patient's meaningful health outcomes, considering baseline functional/cognitive status, chronic conditions, social determinants of health, and life expectancy 1

Step 9: Relevant Laboratory and Imaging Studies

Order tests based on clinical presentation and identified risk factors:

• For fall evaluation: EKG, complete blood count, electrolyte panel, measurable medication levels, appropriate imaging 1
• For cognitive impairment: vitamin B12 level, thyroid function tests, structural neuroimaging 1
• For medication safety: renal function (creatinine clearance), drug levels as indicated 2
• For anticoagulant users: INR/PT if on warfarin 2
• For antidiabetic medication users: immediate glucose check 2

Step 10: High-Risk Factor Identification

Synthesize findings to identify patients at highest risk for adverse outcomes:

Medication-Related Risk Factors

• Polypharmacy (≥5 medications), hyperpolypharmacy (≥9 medications) 1
• Use of high-risk medications (anticoagulants, antidiabetics, opioids, benzodiazepines, NSAIDs, anticholinergics) 1, 3
• Advanced age, female sex, multiple chronic conditions, cognitive impairment, low body weight, creatinine clearance <50 mL/min, frailty 1

Fall Risk Factors

• Age >65, history of falls, difficulty with gait/balance, TUG >12 seconds, inability to hold tandem stand for 10 seconds 1
• Positive P-SCHEME factors (pain, shoes, cognitive impairment, hypotension, eyesight, medications, environment) 1

Psychiatric Risk Factors

• Current suicidal or homicidal ideation, past suicide attempts, history of aggressive behaviors 1
• Substance use disorder, recent changes in substance use 1
• Significant psychosocial stressors, trauma history, lack of social support 1

Cognitive Risk Factors

• MMSE <24, delirium, dementia, inability to manage medications independently 1, 2

Step 11: Follow-Up Planning

Immediate Actions

• For life-threatening conditions: activate emergency medical services immediately 2
• For medication overdose concerns: contact Poison Control Center 2
• For acute delirium: implement comprehensive evaluation to identify and treat reversible causes 1
• For positive fall screen: refer to physical therapy for exercise program and walking aid evaluation 1

Short-Term Follow-Up (Within Days to Weeks)

• Dedicate a visit to comprehensive medication reconciliation and deprescribing 1
• Implement supervised medication administration if cognitive impairment present 2
• Arrange home safety evaluation for fall risk 1
• Initiate exercise program (tai chi, walking, resistance training) to improve balance and strength 1

Ongoing Monitoring

• Reassess medications at every care transition and at least every 3 months 1, 3
• Monitor cognitive function regularly: changes may indicate medication adverse effects or disease progression 1
• Track functional status, fall frequency, and medication adherence 1
• Coordinate care across providers and pharmacies to prevent fragmentation 1
• Store medications in caregiver's home rather than with patient if cognitive impairment present 2

Team-Based Approach

• Integrate pharmacist-led interventions within comprehensive geriatric assessment teams 3
• Coordinate with physical therapy, occupational therapy, social work, and primary care 1

Common Pitfalls to Avoid

• Do not apply disease-specific guidelines without considering multimorbidity and patient-centered goals 3
• Do not use chronological age alone when making prescribing decisions; incorporate functional and cognitive assessments 1, 3
• Do not ignore drug-drug interactions; use screening tools systematically 1
• Do not fail to reassess at care transitions (admission, transfer, discharge) 1, 3
• Do not mistake adverse drug events for new medical conditions, leading to prescribing cascade 1
• Do not discharge patients who cannot rise from bed, turn, and steadily ambulate without reassessment 1
• Do not overlook cognitive impairment as a barrier to medication self-management 1, 2