Medication, Polypharmacy and Patient Safety in Older People’s Care in Norway

An 86-year-old woman returns home after a hospital admission with several changes to her medication. Her general practitioner still holds the longer-standing treatment history. Municipal home nursing is responsible for helping her take medicines each day. A multidose supply has already been prepared using the previous regimen, while her daughter has a handwritten list from before the admission.

Nothing in that situation is unusual. Yet it illustrates why medication safety has become such an important part of Norway’s ageing and long-term care system. Across the wider Norway Ageing, Long-Term Care & Community Support Knowledge Hub, the challenge is increasingly not whether older people receive medicines, but whether the complete treatment picture remains accurate, proportionate and understood as people move between services.

Older people are more likely to live with several chronic conditions and to use several medicines simultaneously. Polypharmacy can be entirely appropriate when each medicine has a clear purpose and the overall regimen remains beneficial. The risk arises when treatment accumulates faster than it is reviewed, information becomes fragmented, side effects are mistaken for new disease, or responsibility becomes unclear between prescribers and care settings.

Norway’s response increasingly combines national guidance, professional responsibility, medication reconciliation, systematic medication review, digital infrastructure, pharmacy involvement and municipal governance. The central operational challenge is making those components work as one safety system around the individual.

Polypharmacy is not automatically inappropriate

The term polypharmacy is often used as though the number of medicines alone defines unsafe practice. That is too simplistic.

An older person with heart failure, atrial fibrillation, diabetes and osteoporosis may appropriately require several medicines. Removing treatment merely to reduce the count can be as unsafe as leaving unnecessary medicines in place.

The stronger question is whether each medicine still has:

• a current clinical indication;
• a dose appropriate to age, kidney function and other conditions;
• a benefit that remains meaningful for the person;
• acceptable interactions with other medicines;
• a monitoring plan where one is required; and
• a place within the person’s wider goals of care.

Older age changes the balance because physiological reserve can fall, kidney function may alter drug clearance and susceptibility to dizziness, sedation, bleeding, delirium and falls can increase.

This means medication safety in later life is closely connected with medicines, frailty, falls and safety. A treatment decision cannot be judged only through the disease it targets. Its effect on mobility, cognition, continence, nutrition, sleep and independence also matters.

Norway has made appropriate medication use a national patient-safety priority

The Norwegian Directorate of Health’s National Plan for Appropriate Medication Use brings several existing safety measures into one framework. Its purpose is to reduce medication-related patient harm and strengthen more preventive use of medicines across health and care services.

The plan focuses particularly on reducing inappropriate polypharmacy, medication errors during transitions, errors in high-risk situations, insufficient awareness of medication-related risk and gaps in the tools used by health professionals, patients and relatives.

This is significant because it frames medication safety as more than a prescribing issue.

The pathway includes maintaining an accurate overview of what the patient actually uses, appropriate prescribing, checking the whole medication regimen, safe preparation and administration, and active involvement of the patient and relatives where appropriate.

That broader framing matters operationally. A prescription can be clinically correct and still lead to harm if the wrong medicine is subsequently dispensed, the care record contains an outdated dose or staff do not know that treatment was stopped during a hospital admission.

Medication safety therefore depends on risk management and compliance across multiple handovers rather than on one professional decision alone.

The fastlege remains an important coordinator

For many older people living at home, the fastlege — the regular general practitioner — has a central role in ongoing medication treatment.

That role becomes more demanding when a patient sees hospital specialists, emergency clinicians and other prescribers. New medicines may be started by one service while another remains responsible for long-term monitoring.

Norwegian guidance therefore places importance on medication review for people using multiple medicines.

General practitioners are required to consider the need for a medication review for patients who use four or more medicines regularly when this is medically necessary. For older people with multimorbidity, the practical value is not the numerical threshold itself. It is the opportunity to revisit accumulated treatment as a whole.

A good review may identify a medicine that is no longer necessary, an inappropriate dose, an interaction, a missing treatment or a symptom caused by another drug.

It may also expose a more fundamental problem: nobody has been looking at the complete regimen because each condition has been managed separately.

Medication reconciliation answers a different question from medication review

Two processes are particularly important in Norway: legemiddelsamstemming, medication reconciliation, and legemiddelgjennomgang, medication review.

They are related but not interchangeable.

Medication reconciliation establishes what the patient is actually taking. That can require comparison between the patient’s account, prescriptions, multidose information, discharge documents, medication packages, care records and information from relatives.

Medication review then asks whether that treatment is clinically appropriate.

The distinction matters because it is impossible to review the safety of an inaccurate list.

A medication may appear active in one system but have been discontinued. A person may take an over-the-counter medicine not recorded by their doctor. Another may be taking an older dose because a change never reached the home-care team.

Norwegian national professional advice therefore emphasises both clear organisational routines and sufficient staff competence for reconciliation and review.

Responsibility also belongs at management level. Organisations need routines that describe who does what, how multidisciplinary input is obtained, when reviews should occur and how patient involvement is incorporated.

Scenario: a fall is treated as a medication signal

An 82-year-old man living at home receives municipal home nursing twice each day. He has hypertension, chronic pain, insomnia and mild cognitive impairment. Over six months, he has fallen three times.

Each fall could be treated as a separate mobility event. Instead, the municipal nurse notices that the falls occur mostly when he gets up during the night and raises the pattern with his general practitioner.

Medication reconciliation identifies that he is taking a sleeping medicine regularly, an opioid prescribed after an earlier injury and two blood-pressure medicines. His daughter also reveals that he occasionally uses an over-the-counter antihistamine at night because he believes it helps him sleep.

The general practitioner reviews the overall regimen rather than concentrating on one drug. Blood pressure is checked in different positions, pain treatment is reconsidered and a gradual reduction plan is agreed for medication contributing to sedation.

Home nursing monitors sleep, pain, dizziness and further falls over the following weeks.

The important control is the connection between an observable outcome and prescribing. If falls data sit separately from medication data, the opportunity for prevention can be missed. When staff are expected to recognise medication-related patterns, routine care becomes part of the safety system rather than simply the administration of tablets.

Nursing homes have explicit medication-review responsibilities

Medication review has particular importance in Norwegian nursing homes because long-term residents frequently live with extensive assistance needs, multimorbidity and cognitive impairment.

Norwegian regulations require systematic medication review for long-term nursing-home residents on admission and at least annually, as well as when necessary to ensure safe treatment.

The review is led by a doctor and may involve other health professionals.

Yet national quality data demonstrate that formal requirements do not automatically produce uniform implementation. In 2025, 62.3 per cent of long-term nursing-home residents aged 67 and over were recorded as having received a medication review during the previous 12 months.

The reported proportion ranged from more than 90 per cent in Oslo to less than half in Vestland.

Registration practices affect the data and caution is necessary when comparing areas. Even so, such variation creates a legitimate governance question.

Municipalities need to know whether the gap reflects incomplete documentation, insufficient review capacity, variable clinical practice or a combination of these factors.

This is where quality data and performance metrics should prompt investigation rather than being treated as an end in themselves.

Transitions between hospital and municipal care remain one of the highest-risk points

Medication errors are particularly likely when older people move between care settings.

A hospital may stop one drug, change the dose of another and add treatment intended only for a short period. On discharge, responsibility returns to general practice, municipal home services or a nursing home.

If each service holds a different medication list, the clinical reasoning behind those changes can be lost.

This risk is structural. Norwegian general practitioners, hospitals and municipal services have historically used different electronic record systems, and medication information has not always updated automatically across them.

For the person receiving care, that fragmentation can produce very practical consequences: duplicate medicines, accidental continuation of discontinued treatment, omitted doses or uncertainty about which prescriber should review a new drug.

Medication reconciliation at transitions is therefore a major safety control.

The stronger process does not simply copy the hospital discharge list into another record. It establishes what changed, why it changed, what should continue and what follow-up is required.

This connects naturally with transitions between hospital and home-based care, where medication information must travel with the person rather than remain attached to the organisation that last treated them.

Scenario: three medication lists after discharge

A 90-year-old woman returns home following treatment for heart failure. Before hospital admission, home nursing administered medicines from a multidose roll. During admission, a diuretic dose was changed, one blood-pressure medicine was stopped and a short course of another treatment was started.

On the first evening home, the municipal nurse discovers three different sources of information: the previous multidose packets, the new hospital discharge summary and the medication list already held in the local electronic care record.

The nurse does not simply select the newest-looking list.

The discrepancy is escalated and reconciled. The home-care team confirms which medicines should be administered immediately, contacts the appropriate prescriber where clarification is required and prevents the old multidose supply from being used without review.

A new dispensing arrangement is organised and the general practitioner receives responsibility for defined follow-up.

The woman’s weight and symptoms are monitored because the diuretic dose has changed.

The incident is then considered at service level. Leaders ask whether staff consistently know what to do when a patient returns before a new multidose roll is available, whether discharge information reaches the correct team quickly enough and whether out-of-hours escalation is sufficiently clear.

The immediate discrepancy is resolved for one person, but the governance value lies in using it to strengthen the pathway for the next discharge.

Multidose dispensing can improve safety, but it changes the workflow

Multidose dispensing is widely relevant to older people receiving municipal care in Norway.

Medicines that can be packaged are machine-dispensed into small labelled sachets showing the individual, date and administration time. For suitable people, multidose can simplify complex regimens, reduce manual preparation by nurses and support more consistent administration.

But it is not appropriate for every medication pathway.

The Directorate of Health identifies suitability particularly where people take several regular medicines that can be packaged, treatment does not change frequently and the person or care service benefits from clearer dose organisation.

That qualification is crucial.

A rapidly changing medication regimen can create tension between clinical decisions and the dispensing cycle. A medicine may be changed today while previously prepared packets still contain yesterday’s regimen.

This means multidose does not remove the need for medication reconciliation or professional judgement. It changes where control is required.

Effective use depends on coordination between the patient, doctor, municipality and pharmacy.

It also means that staff need clear procedures for urgent changes, temporary medicines, medicines that cannot be packed and disposal or correction of obsolete packets.

The wider lesson is applicable to automation and workflow design: automated systems can reduce manual burden, but safe automation depends on accurate inputs and reliable exception processes.

Administration safety depends on workforce competence

Medication safety continues after prescribing and dispensing.

Municipal health and care services need sufficient competence to prepare, administer and monitor medicines safely.

That can involve tablets and liquids, but also insulin, anticoagulants, eye drops, inhalers, injections, patches and medicines used only when required.

The risk increases when the workforce is stretched or responsibilities are redistributed.

Task-sharing can be entirely appropriate where staff have documented competence, instructions are clear and professional oversight remains available. It becomes unsafe when delegation is used simply to bridge staffing gaps without analysing the medication risk.

A member of staff may be technically able to hand over a multidose sachet but still need to recognise that the resident is unusually drowsy, unable to swallow or showing signs of acute deterioration.

Safe administration therefore combines procedural competence with observation and escalation.

This is part of the wider workforce and skill-mix challenge in older people’s care. Increasing efficiency cannot mean disconnecting medication tasks from clinical awareness.

High-risk medicines require additional attention

Some medicines create disproportionate risk for older people because the consequences of error or side effects can be severe.

Anticoagulants can contribute to serious bleeding. Insulin errors can produce dangerous blood-glucose changes. Opioids and sedatives may contribute to respiratory depression, delirium and falls. Medicines with significant anticholinergic effects can worsen cognition and constipation. Non-steroidal anti-inflammatory drugs may pose particular risks for renal, gastrointestinal and cardiovascular health.

Norway’s national medication plan therefore includes monitoring of prescribing of several higher-risk categories among people over 65.

The governance requirement is not that such medicines should never be used.

It is that services should know where the higher-risk points are and design stronger controls around them.

Those controls may include monitoring, double-checking, laboratory follow-up, review after dose changes or clearer escalation thresholds.

A proportionate approach to internal controls and assurance should therefore concentrate additional attention where the potential for harm is greatest rather than treating every medication task as identical.

Medication and dementia create additional rights and consent questions

Medication decisions can become more complex where an older person has dementia and impaired decision-making capacity.

The clinical question remains whether medication is appropriate, but the legal basis for treatment and the person’s involvement also matter.

Norwegian law changed from 1 June 2026 in ways relevant to the use of psychotropic medication for some people with dementia and serious mental illness. The change affects the legal basis for particular forms of treatment; it does not create a general justification for routine psychotropic prescribing in nursing homes.

National professional guidance continues to support restrictive and clinically justified use.

This distinction is particularly important where sedating medication risks being used as a response to distress that may have environmental, interpersonal, physical or communication causes.

A resident who repeatedly calls out may be in pain, frightened, constipated, lonely or unable to understand what is happening around them.

Medication can sometimes be clinically necessary, but it should not become the automatic substitute for investigation and person-centred support.

This connects with dementia, distress and meaningful activity and with the wider responsibility to preserve dignity and autonomy wherever possible.

Scenario: antipsychotic treatment is reviewed rather than inherited

An 87-year-old nursing-home resident with dementia was prescribed an antipsychotic medicine during an earlier period of severe distress. Several months later the medication remains on the chart, although the original crisis has settled.

A routine medication review does not begin with the assumption that the drug must be stopped. The nursing-home doctor and care team first reconstruct why it was started, what symptoms were present, whether non-drug measures were tried and what has happened since.

Staff report that the resident is now sleeping for much of the morning and has become less steady when walking. Her daughter says she appears less engaged than before.

The team agrees that the balance of benefit and harm should be reassessed. A cautious reduction is planned, with staff monitoring sleep, distress, mobility and behaviour rather than simply recording whether the medicine was administered.

The review therefore links prescribing to observable outcomes.

If distress returns, the team will examine the context before automatically restoring the previous dose. If mobility and alertness improve without significant deterioration, that evidence informs the next decision.

The case demonstrates why medication review is a clinical process rather than a documentation exercise. A prescription should not continue indefinitely merely because the circumstances that originally produced it have disappeared from organisational memory.

Patients and relatives need an active role in medication safety

Norway’s medication-safety approach increasingly recognises patients and relatives as active participants rather than passive recipients.

For older people living independently, this includes knowing what medicines they use, why they use them and what important side effects should prompt advice.

Helsenorge provides access to prescription information, while people using many medicines are encouraged to keep an updated medication list and discuss treatment regularly with their general practitioner.

Family involvement can be especially valuable where cognitive impairment or sensory loss makes medication management difficult.

But relatives should not be expected to compensate indefinitely for an unsafe formal system.

A daughter who notices that two lists do not match can provide an important warning. Responsibility for resolving that discrepancy still belongs with the relevant health professionals.

Person-centred medication support therefore needs to balance involvement with accountability.

The wider co-production, choice and control principle is particularly important when treatment decisions involve trade-offs between longevity, symptom relief, side effects, cognition and independence.

Digital medication information could remove one of the system’s recurring hazards

One of the most important developments in Norwegian medication safety is Pasientens legemiddelliste, the Patient Medication List.

The intended model is a shared and updated overview of the patient’s medication treatment across health and care services, electronic record systems, the national prescription infrastructure and the national core health record.

Its importance is easy to understand.

A significant proportion of medication risk arises because different parts of the system hold different versions of what the person is taking.

A reliable shared list could reduce the time professionals spend reconstructing treatment and reduce errors caused by incomplete information.

However, this needs accurate status description.

The Patient Medication List is not yet a completed national system everywhere. It remains in phased implementation, with national rollout planned during 2026–2029.

That distinction matters because digital aspiration should not be presented as current universal practice.

During the transition period, organisations still need robust reconciliation processes even where new digital tools are being introduced.

The Digital Transformation Readiness Assessment offers organisations examining comparable reforms a way to test governance, infrastructure, workforce adoption and digital resilience. It does not assess compliance with Norway’s Patient Medication List programme.

Digital systems do not remove the need for reconciliation

A shared medication list can reduce fragmentation, but it cannot automatically determine whether treatment is clinically correct.

The distinction between data accuracy and clinical appropriateness remains.

A perfectly synchronised list can still contain unnecessary medication.

Equally, a new prescription can be entered correctly but become unsafe because renal function deteriorates or the person’s goals of care change.

Digitalisation therefore needs to support three different activities:

• making current medication visible;
• helping professionals identify interactions, duplication and risk;
• supporting reliable communication when treatment changes.

It cannot replace professional review or conversations with the person receiving treatment.

This is also why interoperability and system integration should be understood as a patient-safety issue rather than an information-technology objective alone.

Medication incidents should generate system learning

An individual medication error may appear simple: the wrong dose was given, a medicine was missed or an outdated multidose packet was used.

The governance question is what allowed the event to occur.

Repeated missed doses may reflect confusing records. A double dose may expose poor handover between shifts. Delayed implementation of a prescribing change may reveal weak communication between a doctor, pharmacy and municipal service.

Incident learning therefore needs to move beyond identifying the person who made the final error.

Leaders should examine recurring patterns across the pathway.

Useful questions include whether discrepancies cluster around hospital discharge, whether certain high-risk medicines appear disproportionately in incidents, whether staff competence needs strengthening and whether digital systems are introducing new failure modes.

The Quality Dashboard Builder can help organisations structure comparable medication-safety information alongside incidents, outcomes and improvement actions. It is not a Norwegian reporting system, but it illustrates how operational data can be converted into governance visibility.

Scenario: repeated missed doses reveal a workflow defect

A municipality notices several incidents involving evening medication among people receiving home nursing.

Initially, each event is treated separately. In one case staff arrived after the person had gone to bed. In another, the electronic visit list displayed the medication task incorrectly. In a third, a temporary agency worker did not realise that one medicine had to be given at a specific time.

A thematic review shows that the common issue is not individual carelessness.

The evening route has become increasingly compressed, time-critical medicines are not sufficiently visible in scheduling and medication competence varies between staff groups.

The municipality redesigns the route so that high-priority medication visits are identified separately from flexible support visits. Staff instructions are simplified, competency requirements are checked and managers begin monitoring missed and delayed doses by cause.

The improvement is therefore operational rather than disciplinary.

If governance had looked only at whether each incident form was completed, the recurring system weakness could have remained hidden.

This is the practical value of learning from incidents and continuous improvement: repeated small events can reveal structural risk before they produce more serious harm.

Pharmacists can strengthen medication review and transition safety

Medication management is not exclusively the work of doctors and nurses.

Pharmacists bring specialist expertise in interactions, dosing, formulation and the practical management of complex treatment.

Norwegian guidance recognises that health professionals with particular medication expertise, including pharmacists, can support doctors in preparing for medication review.

Pharmacy involvement is also important in multidose dispensing and patient advice.

The value is greatest where roles are integrated rather than parallel.

A pharmacist can identify a potential interaction, but someone still needs authority to decide what treatment should change. A municipal nurse may recognise that the person is becoming dizzy. A general practitioner may hold the overall prescribing responsibility. The resident or relative may know whether the medicine is actually being taken.

Medication safety is strongest when those perspectives connect.

Governance needs to measure more than whether a review occurred

Medication-review rates are useful, but they are a process measure.

A municipality can achieve a high review rate while still experiencing poor medication outcomes if reviews are superficial or identified actions are not followed through.

Stronger assurance connects process with effect.

Depending on the population, governance may examine:

• completion and timeliness of medication reconciliation after transitions;
• medication reviews and resulting treatment changes;
• falls associated with sedating or blood-pressure-lowering medicines;
• errors in preparation and administration;
• high-risk medicine incidents;
• resident or patient understanding of their treatment; and
• whether improvement actions reduce recurrence.

The Governance Maturity Assessment can help organisations exploring comparable accountability questions examine whether responsibility, escalation and assurance are sufficiently mature, while remaining separate from Norway’s own regulatory requirements.

The future challenge is reducing medication burden without undertreating older people

As Norway’s oldest population grows, medication use is likely to remain an increasingly important part of long-term care.

The future objective cannot be to eliminate polypharmacy.

It should be to reduce inappropriate polypharmacy while maintaining treatments that genuinely improve health, comfort and function.

That will require more regular review, better information sharing, stronger decision support and greater attention to deprescribing where benefit has become uncertain or harm is emerging.

It will also require clinicians to discuss outcomes that matter to the individual.

For a robust 70-year-old, long-term preventive treatment may have one balance of benefit and burden. For a 94-year-old with severe frailty and limited life expectancy, the same treatment may require a different discussion.

This is not discrimination by age. It is personalised medicine.

Norway’s stronger opportunity lies in connecting digital medication infrastructure with the clinical and person-centred judgement required to make those distinctions well.

What other systems can learn from Norway

Norway’s medication framework operates within a health system shaped by regular general practitioners, municipal health and care services, national digital infrastructure and publicly funded provision. Those institutions cannot simply be transplanted elsewhere.

The transferable lesson lies in how medication safety is framed.

Safe treatment is not achieved by prescribing alone. It requires a reliable chain from the medication decision through reconciliation, dispensing, administration, monitoring, patient understanding, review and discontinuation.

It also requires recognition that transitions are predictable risk points and that digital fragmentation can become a clinical hazard.

Other systems could adapt that principle without copying Norway’s mechanisms: identify where medication information becomes fragmented, define responsibility at handovers and make systematic review part of routine care for people with complex treatment.

The comparison highlights a shared challenge rather than a single institutional answer.

Conclusion

Medication is one of the most powerful tools in older people’s care, but its value depends on the complete treatment system around it.

Norway’s ageing population means more people will live for longer with multimorbidity, frailty and several simultaneous medicines. That makes polypharmacy an increasingly important governance issue, but the objective is not simply to reduce the number of prescriptions. It is to ensure that each treatment remains purposeful, proportionate and safe.

The strongest safeguards connect general practice, specialist healthcare, municipal home services, nursing homes, pharmacies, patients and families around an accurate medication picture. Medication reconciliation establishes what is actually being taken. Structured review determines whether it is still appropriate. Competent administration, monitoring and incident learning protect people once prescribing decisions enter everyday care.

Digital developments such as the Patient Medication List could reduce one of Norway’s persistent risks: different services holding different versions of the same person’s treatment. Their value, however, will depend on implementation, professional adoption and reliable clinical governance.

The central strategic task is therefore not technological or pharmaceutical in isolation. It is organisational. Medication safety improves when information, judgement and accountability travel with the person across the whole care pathway. For Norway, that connection will become increasingly important as more complex treatment is delivered at home and the people entering institutional care do so with greater levels of frailty and dependency.