prescription-appropriateness-review — independently scanned and version-tracked by SaferSkills.
SaferSkills independently audited prescription-appropriateness-review (Agent Skill) and scored it 100/100 (green). The audit ran 55 deterministic rules across Security, Supply Chain, Maintenance, Transparency, and Community; it found 0 high-severity and 0 lower-severity findings. The full rule-by-rule trace and per-finding evidence are below. Free, methodology-open.
Findings & checks · 0 flagged
Every scanned point with the score it earned and what moved between them.
First recorded scan — no prior version to compare against.
The primary manifest — the file an agent reads to learn what this artifact does.
Perform a comprehensive prescription appropriateness review by applying AGS 2023 Beers Criteria for patients aged 65 and older, STOPP/START criteria for potentially inappropriate prescribing and prescribing omissions, renal dose adjustments based on eGFR from laboratory Observations, and hepatic dose adjustments. Flag anticholinergic burden, CNS-active polypharmacy, and prolonged PPI use.
| Resource | Purpose | Key Fields |
|---|---|---|
| Patient | Age determination, demographics | birthDate, gender |
| MedicationRequest | Active prescriptions to review | status, medicationCodeableConcept, dosageInstruction, reasonCode |
| MedicationStatement | Patient-reported medications including OTC | status, medicationCodeableConcept, dosage |
| Condition | Active diagnoses for drug-disease interaction checks | code, clinicalStatus, onsetDateTime |
| Observation | Lab values for renal/hepatic function | code, valueQuantity, effectiveDateTime |
| AllergyIntolerance | Cross-reference for contraindicated meds | code, clinicalStatus |
Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"Calculate age from birthDate. Beers Criteria apply to patients >= 65 years. STOPP/START criteria apply to patients >= 65 years. Renal/hepatic dose adjustments apply to all ages.
Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&_count=100"Tool: fhir_search
resourceType: "MedicationStatement"
queryParams: "patient=[patient-id]&status=active&_count=100"Merge and deduplicate by RxNorm code. For each medication, extract: name, dose, frequency, route, indication (if available via reasonCode).
Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active&_count=100"Extract SNOMED CT or ICD-10 codes. Key conditions to identify:
Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=33914-3,77147-7,48642-3&_sort=-date&_count=1"LOINC codes for eGFR:
Also pull serum creatinine:
Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=2160-0&_sort=-date&_count=1"LOINC 2160-0: Serum creatinine (mg/dL)
Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=1742-6,1920-8,1975-2,14631-6&_sort=-date&_count=4"LOINC codes:
If ALT/AST > 3x upper limit of normal or bilirubin elevated, apply hepatic dose adjustments.
Cross-reference each active medication against the AGS 2023 Beers Criteria (see references/beers-criteria.md). Evaluate in order:
Table 1: Medications to Potentially Avoid in Older Adults Flag any medication on the Beers avoid list regardless of diagnosis.
Table 2: Medications to Potentially Avoid Due to Drug-Disease/Drug-Syndrome Interactions Cross-reference active conditions against medications. Flag any condition-medication pair.
Table 3: Medications to Use with Caution Flag medications requiring extra monitoring or dose limits.
Table 4: Drug-Drug Interactions to Avoid Check medication pairs against Beers interaction table.
Table 5: Medications to Avoid or Reduce Based on Kidney Function Apply eGFR-based restrictions.
STOPP (Screening Tool of Older Persons' Prescriptions): Cross-reference active medications and conditions against STOPP criteria (see references/stopp-start-criteria.md). Identify potentially inappropriate prescriptions.
START (Screening Tool to Alert to Right Treatment): Cross-reference active conditions against START criteria. Identify potential prescribing omissions where evidence-based medications are not prescribed.
Assign anticholinergic burden score to each medication using the Anticholinergic Cognitive Burden (ACB) scale:
| Score | Level | Examples |
|---|---|---|
| 1 | Possible anticholinergic | Furosemide, metoprolol, ranitidine, warfarin |
| 2 | Definite, clinically relevant | Amantadine, carbamazepine, cetirizine |
| 3 | Definite, strong | Amitriptyline, diphenhydramine, oxybutynin, paroxetine |
Total ACB Score Interpretation:
Count concurrent CNS-active medications:
Flag if >= 3 concurrent CNS-active medications. Associated with increased risk of falls, fractures, cognitive impairment, and mortality in older adults.
If patient is on a proton pump inhibitor (omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole):
Cross-reference each medication against renal dosing requirements (see references/renal-dosing.md). For each medication requiring adjustment:
PRESCRIPTION APPROPRIATENESS REVIEW - [Patient Name] (Age [X])
Review Date: [date]
eGFR: [value] mL/min/1.73m2 (Date: [date])
BEERS CRITERIA FLAGS:
1. [Medication] - [Beers category] - [Rationale] - [Recommendation]
Quality of Evidence: [High/Moderate/Low] | Strength: [Strong/Weak]
STOPP CRITERIA FLAGS:
1. [Medication] - [STOPP criterion] - [Rationale] - [Recommendation]
START CRITERIA FLAGS (Potential Omissions):
1. [Condition present] - [Recommended medication not prescribed] - [Evidence]
ANTICHOLINERGIC BURDEN:
Total ACB Score: [N]
Contributing medications: [list with individual scores]
Recommendation: [if score >= 3]
CNS-ACTIVE POLYPHARMACY:
Count: [N] concurrent CNS-active medications
Medications: [list]
Recommendation: [if >= 3]
PPI ASSESSMENT:
Duration: [months/years]
Indication documented: [Yes/No]
Recommendation: [continue/taper/discontinue]
RENAL DOSE ADJUSTMENTS NEEDED:
1. [Medication] - Current: [dose] - Recommended for eGFR [X]: [adjusted dose]
HEPATIC CONSIDERATIONS:
[if applicable]
SUMMARY:
- Total flags: [N]
- Critical (requires immediate action): [N]
- Moderate (review at next visit): [N]
- Informational: [N]User says: "Review prescription appropriateness for patient 78901, age 82, with dementia."
Actions:
Result:
PRESCRIPTION APPROPRIATENESS REVIEW - Patient 78901 (Age 82)
eGFR: 42 mL/min/1.73m2
BEERS CRITERIA FLAGS:
1. Diphenhydramine 25mg - TABLE 1: Avoid - Highly anticholinergic, cognitive impairment risk
[Strong recommendation, Moderate evidence]
2. Oxybutynin 5mg BID - TABLE 2: Avoid with dementia - Worsens cognitive impairment
[Strong recommendation, Moderate evidence]
3. Zolpidem 10mg - TABLE 1: Avoid - Falls, delirium, fractures. If used, max 5mg.
[Strong recommendation, Moderate evidence]
4. Tramadol 50mg TID - TABLE 1: Use with caution - CNS effects, falls risk, seizure threshold
5. Omeprazole - TABLE 3: Use with caution >8 weeks without indication review
STOPP CRITERIA FLAGS:
1. Oxybutynin with dementia (STOPP B7) - Anticholinergic worsens cognition
2. Benzodiazepine-receptor agonist (zolpidem) with falls risk (STOPP K1)
3. First-generation antihistamine (diphenhydramine) long-term (STOPP B1)
ANTICHOLINERGIC BURDEN:
Total ACB Score: 8 [CRITICAL]
- Diphenhydramine: 3
- Oxybutynin: 3
- Escitalopram: 1
- Metoprolol: 1
Recommendation: URGENT reduction. Target ACB <= 2. Discontinue diphenhydramine and oxybutynin.
CNS-ACTIVE POLYPHARMACY:
Count: 5 [CRITICAL]
- Tramadol, Zolpidem, Gabapentin, Escitalopram, Diphenhydramine
Recommendation: Reduce to <= 2 CNS-active medications.
RENAL DOSE ADJUSTMENTS:
1. Gabapentin: Current 300mg TID. For eGFR 42: Max 300mg BID. Reduce.
2. Tramadol: Extended-release contraindicated if eGFR <30. Currently ok but monitor.
RECOMMENDED ACTIONS:
1. [URGENT] Discontinue diphenhydramine. Use melatonin 1-3mg for sleep if needed.
2. [URGENT] Discontinue oxybutynin. Consider mirabegron (beta-3 agonist, non-anticholinergic).
3. [HIGH] Taper zolpidem. If continued, reduce to 5mg max.
4. [HIGH] Reduce gabapentin to 300mg BID for CKD.
5. [MODERATE] Review tramadol necessity. Consider topical alternatives.
6. [MODERATE] Reassess omeprazole indication for deprescribing.User says: "Check if patient 34567, age 72 with diabetes and heart failure, is missing any recommended medications."
Actions:
Result:
PRESCRIPTION APPROPRIATENESS REVIEW - Patient 34567 (Age 72)
START CRITERIA FLAGS (Potential Omissions):
1. ACE inhibitor or ARB - Not prescribed. START A3: ACE/ARB indicated for HFrEF.
Also START A5: ACE/ARB for diabetic nephropathy (check urine albumin).
2. Statin - Not prescribed. START A3: Statin indicated for diabetes age 40-75.
LDL 135 mg/dL is above goal (<70 for diabetes + HF).
3. SGLT2 inhibitor - Not prescribed. START: SGLT2i (dapagliflozin, empagliflozin) indicated
for HFrEF regardless of diabetes status. Dual benefit here.
4. Mineralocorticoid receptor antagonist (spironolactone/eplerenone) - Not prescribed.
Indicated for HFrEF with EF <=35% (if EF confirmed at 35%).
BEERS CRITERIA:
1. Glipizide - TABLE 1: Avoid long-acting sulfonylureas in elderly. Hypoglycemia risk.
Consider: Switch to short-acting or SGLT2i/GLP-1 RA.
RECOMMENDED ACTIONS:
1. [HIGH] Add ACE inhibitor (e.g., lisinopril 5mg, titrate) or ARB. Guideline-directed for HFrEF.
2. [HIGH] Add high-intensity statin (atorvastatin 40-80mg or rosuvastatin 20-40mg).
3. [HIGH] Add SGLT2 inhibitor (empagliflozin 10mg or dapagliflozin 10mg). Check eGFR >= 20.
4. [MODERATE] Add spironolactone 25mg if K+ <5.0. Monitor K+ in 1 week.
5. [MODERATE] Consider switching glipizide to DPP-4 inhibitor or GLP-1 RA (lower hypoglycemia risk).drug-interaction-checker - Complementary interaction analysis beyond Beers Table 4medication-reconciliation - Ensure medication list is complete before appropriateness reviewopioid-risk-assessment - Detailed opioid assessment when opioids flagged by Beersmedication-adherence-assessment - Assess if patient is actually taking the flagged medications~30 seconds. Free. No account. Every finding cites a rule and a line of evidence.