Objective: Potentially Inappropriate Medications (PIMs) and Drug–Drug Interactions (DDIs) among geriatrics are a prominent issue and place a considerable burden on the quality health outcome. This study aimed to assess PIMs and DDIs particularly among geriatric cardiac elderly patients attending the outpatient department of a tertiary care hospital of Nepal.Methodology: A prospective cross‐sectional study was conducted on geriatrics patients (≥ 65 years) attending the cardiology out‐patient department of Bharatpur Central Hospital, Nepal. Beers criteria were used to assess PIM, and Medscape software was employed to assess DDIs. Regression analysis was performed to identify the predictors of PIM and DDIs experienced by patients.Results: A total of 140 geriatric patients were enrolled in the study. A total of 683 drugs were prescribed to them, with an average of 4.59 medications per patient. 23.6% and 65% of patients were found to be prescribed PIMs and encountered DDIs, respectively. Proton Pump Inhibitors (PPI) (66.67%) were the most prescribed PIMs and involved in identified DDIs. The removal of PIMs was calculated to reduce 11.72% of the cost of patients prescribed PIMs and 19.88% of identified DDIs. The number of medications prescribed was found to be a significant predictor for PIM (Odd Ratio: 1.352) and DDIs (Odd Ratio: 2.217) encountered.Conclusion: This study highlights the concerning prevalence of potentially inappropriate medication and drug–drug interactions among ambulatory cardiac elderly patients. Integration of regular medication audits and evidence‐based prescribing practices is essential to optimize pharmacological management and enhance patient safety.

Background: Nepal is experiencing a rapid demographic shift toward an aging population, with concurrent increase in morbidity and medication-related problems. Despite this, the multidimensional experience of medication-related burden (MRB) and refill adherence remain under-studied, particularly through the lens of socio-demographic, clinical and medication-related predictive features. This study aimed to assess MRB and medication adherence, and utilize machine learning (ML) architectures to identify complex factors influencing both. Methods: A cross-sectional study conducted among 390 ambulatory older patients (aged≥65 years) at Bharatpur Hospital, Nepal. MRB and medication adherence was assessed using Living with Medications Questionnaire (LMQ-3) and Adherence to Refills and Medication Scale (ARMS). Six ML architectures (Ordinary Least Square, LightGBM, Random Forest, XGBoost, SVM, and Penalized linear regression) were employed to predict ARMS and LMQ scores using various socio-demographic, clinical and medication-related predictive features. Model explainability was provided through SHAP (Shapley Additive exPlanations). All the analysis were performed using R. Results: The median LMQ-3 score was 110.0 (IQR 14.0), reflecting a moderate medication-related burden, while the median ARMS score of 21.0 (IQR 6.0) indicated moderate non-adherence. Random forest was the superior predictive model for both MRB and adherence. SHAP analysis revealed requiring assistance for medication and polypharmacy as the most significant drivers of both increased burden and poor adherence. Interaction analysis revealed that while polypharmacy typically worsens adherence, the risk is partially mitigated when patients receive physical or cognitive assistance. Additional, financial factors and employment status emerged as significant predictors. Conclusion: Older patients in Nepal face a significant medication-related burden and non-adherence, driven largely by regimen complexity and the need for support. The high predictive accuracy of ML models suggests that clinical interventions should prioritize simplified regimens and patient-centered counseling for those with high dependency. These findings provide a data-driven rational for policy-level medication optimization strategies in Nepal’s evolving healthcare system. Author Summary: As ageing occurs, there is high chance of presence of the chronic conditions. For management of these conditions, older people are often prescribed with multiple medications and often are vulnerable to those medications whose risk outweighs benefits. As a result there is high chance of occurrence of adverse effects; these effects have caused substantial degradation of the health related quality of life. Although pharmacotherapy is the mainstay of the chronic disease management, older people often feel medication burden. Medication burden is practical experience arising from the practical and psychological challenge while managing medications. Research shows high burden causes the non-adherence, a significant problem among older adults, causing significant problem in pharmacotherapy. Hence, we used validated Questionnaire for assessing the medication burden and medication adherence among older ambulatory adults attending the central hospital of Nepal. We used machine learning approach for the high prediction of the predictors influencing the medication related burden and mediation adherence. Moderate burden was observed among older adults and moderate non-adherence was also observed. We found needing assistance for medication management and multiple medications were the strongest predictors for both Medication burden and non-adherence. Our Study provides new insights and area for the implementation of clinical intervention for the medication optimization.

The global shift toward patient-centered clinical pharmacy services is governed by Good Pharmacy Practice (GPP) standards. However, implementing these in low-middle income countries (LMICs) remains challenging due to resource and infrastructure constraints. This study aimed to implement GPP standards at a central tertiary hospital using the Plan-Do-Study-Act (PDSA) cycle. A prospective, interventional quality improvement study was conducted at a tertiary care central hospital over five months. Intervention included functional decentralization of services, development of 21 Standard Operating Procedure (SOPs) using the ALCOA+ framework, and staff training. Four longitudinal audits were performed using an expanded 125-indicator Department of Drug Administration (DDA) checklist. Root cause analysis (RCA) via the “5 Whys” technique addressed implementation barriers. Overall median GPP compliance increased from 57.1% (IQR: 25.0%–77.8%) to 100.0% (IQR: 100.0%–100.0%) by final audit (p < 0.0001). High-compliance domains rose from 17.6% to 88.2%. The Hodges-Lehmann estimator indicated a median improvement of 43.7% (95% CI: 22.2% - 62.5%). Qualitative analysis revealed that documentation gaps were rooted in ergonomic friction rather than incompetence; relocating logbooks to dispensing counters resolved these issues. A ceiling effect was observed in store management (91.7% compliance) due to fixed architectural constraints. The PDSA model is an effective framework for driving rapid quality improvement in resource-limited pharmacy settings. Success was achieved not only through procedural changes but by transitioning staff culture from a “money-driven” mindset to “professional ownership”. This study provides a scalable roadmap for GPP implementation and suggests that national audit tools should adopt tier-specific indicators for tertiary facilities.