Peninsula Community Health GUIDELINES FOR PATIENT SELF-ADMINISTRATION

Peninsula Community Health
GUIDELINES FOR
PATIENT SELF-ADMINISTRATION
OF MEDICATION (SAM)
Title:
Guidelines for Patient Self-Administration of
Medication (SAM)
Procedural Document Type:
Guideline
Reference:
CGP20
Version:
1
Approved by:
Matrons Meeting (November 2011)
Ratified by:
Clinical Quality and Safety Committee
Date ratified:
5th December 2011
Name of originator/author:
Ros Palmer & Teresa Finnegan & Adrienne
Darko - Admin
Name of responsible team:
Pharmacy & Nursing Team
Review Frequency:
3 years
Review date:
October 2014
Target audience:
Community Hospital - Medical, Nursing and
Pharmacy staff
Executive Signature (hard copy only):
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Contents
1
2
3
4
5
6
7
8
9
10
Version 1
Introduction.................................................................................................….…4
Definitions...........................................................................................................4
Equality Impact Assessment...............................................................................5
Good Corporate Citizen ......................................................................................5
Duties .................................................................................................................5
Patient Self-Administration of Medication while in Hospital ................................5
6.1 Aims ………………………………………………………………………………6
6.2 Patient Selection…………………………………………………………………6
6.3 Patient Assessment……………………………………………………………..7
6.3 Patient Assessment Self Administration Levels ……………………………..7
6.4 Patient Consent…………………………………………………………… ……9
6.5 Patient Education………………………………………………………………..9
6.6 Prescribing, Storage and Dispensing Medications for SAM………………..9
6.7 Administration and Documentation………………………………………….. .12
6.8 Transfer of Patients………………………………………….………………….15
6.9 Discharge of Patients…………………………………….……………………..15
Risk Management Strategy Implementation .....................................................15
7.1 Implementation...........................................................................................15
7.2 Training and Support..................................................................................16
7.3 Dissemination.............................................................................................16
7.4 Storing the Procedural Document ..............................................................16
Process for Monitoring Effective Implementation..............................................16
Associated Documentation ...............................................................................16
References .......................................................................................................17
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Appendices
Appendix 1 Self Administration Assessment and Consent Form and Continuation Sheet……18
Appendix 2 Self Administration Levels………………………………… …………………………..20
Appendix 3 SAM Quick Reference Guide………………… ……………………………………….20
Appendix 4 SAM Flow Chart …………………………………………………………………………21
Appendix 5 Variance Form……………………………………………………………………………22
Appendix 6 Patient Information Sheet……………………………………………………………….24
Appendix 7 Medicines Reminder Sheet……………………………………………………………..26
Appendix 8 Patient Tick Chart for Regular Medicines……………………………………………..28
Appendix 9 Patient Tick Chart for 'As Required' Medicines…………………………………..…..30
Appendix 10 Self Medication Compliance Checklist……………………………………………….32
Appendix 11 Quick Reference Guide on Essential Documentation……………………………...34
Appendix 12 Assessing Patient’s Own Medicines for Use on the Ward………………………...35
Appendix 13 The (Relevant) NMC Standards for Medicines Management (2008)………….... 36
Appendix 14 NMC Standard 9 - Standards for Practice of Administration of Medicines………38
Appendix 15 NMC Standard 10 – Self-Administration – Children and Young People …………40
Appendix 16 NMC Standard 16 - Aids to Support Compliance………………………….………. 41
Please Note the Intention of this Document
This Guideline sets out the process to be followed by Nursing Staff caring for inpatients in a
Peninsula Community Health community hospital, who would like to self-medicate during their
hospitalisation. It also gives guidance on how to support patients who may not be selfmedicating on admission but who will be required to on discharge.
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1.0 Introduction
These Self-Administration of Medication (SAM) Guidelines enable patients to administer
their own medications whilst in hospital. The Audit Commission Briefing recommends
that patients should be encouraged to self-administer their medications whilst in hospital
as part of the medicine management strategy (Audit Commission, 2001). The Nursing
and Midwifery Council (NMC) supports SAM and the administration of medication by
carers/parents wherever it is appropriate, provided the essential safety, security and
storage arrangements are available and agreed procedures are in place (see Appendix
15 and Appendix 16) (NMC 2008, Standard 9 and Standard 10). Self-Administration is
also encouraged for children who are age appropriate and/or have a sufficient
understanding of their treatment or whose parent/carer wishes to take part.
Objectives of Self- administration of Medication (SAM) at Peninsula Community Health
(PCH).
1.
2.
3.
4.
5.
Maintain patient independence in self-administration of medication where
medication changes are minimal.
Improve patient knowledge and skills where gaps are identified, thereby
increasing independence and concordance on discharge.
Possibly reduce re-admission due to treatment failure caused by noncompliance.
Highlight medication related problems prior to discharge e.g. poor eyesight or
complex packaging/medication regimes, understanding of labelling.
Maintain independence and maximum therapeutic benefit for those patients who
are on complex timed regimes that do not correspond with the timings of the
traditional drug round e.g. Parkinson’s disease.
The purpose of this guideline is to provide healthcare professionals with a framework for
the safe and effective implementation of SAM at PCH.
These guidelines can be applied on any ward within PCH provided that the necessary
facilities and governance arrangements described in this document are in place to
support SAM.
2.0 Definitions
Self-Administration of Medication (SAM) is the process where a patient, following
assessment is able to administer their own medicines whilst in hospital.
Patient - A service user being cared for in one of Peninsula Community Health
Community Hospitals
Nurse - A Healthcare professional registered as a Nurse with the Nursing and Midwifery
Council.
Pharmacist - A Healthcare Professional who is registered as a Practising Pharmacist
with the General Pharmaceutical Council.
Doctor- A Healthcare Professional who is registered as a Medical Practitioner with the
General Medical Council
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3.0
Equality Impact Assessment
Peninsula Community Health aims to design and implement services, policies and
measures that meet the diverse needs of our service, population and workforce,
ensuring that none are placed at a disadvantage over others.
As part of its development, this strategy and its impact on equality have been reviewed
in consultation with trade union and other employee representatives in line with the
Equality and Diversity Policy. The purpose of the assessment is to minimise and if
possible remove any disproportionate impact on employees on the grounds of race sex,
disability, age, sexual orientation or religious belief. No detriment was identified.
The Equality Impact Assessment Tool has been used to help consider the needs and
assess the impact of this policy and has been completed alongside this document.
4.0
Good Corporate Citizen
As part of its development, this policy was reviewed in line with the Peninsula
Community Health Good Corporate Citizen Action Plan. The implementation of this
strategy promotes good governance.
5.0
Duties
Development Team, consisting of the Pharmaceutical Adviser, Sisters, Helston
Community Hospital and Launceston General Hospital, and Administration support are
responsible for the development of the procedural document in line with the guidelines
Consultation Team: responsible for reviewing the procedural document and providing
feedback to the procedural document owner.
Integrated Governance Committee responsible for the final review, ratification and
approval of this document.
6.0
Patient Self-Administration of Medication while in Hospital
Patient assessment for SAM is performed by the registered nurse with the involvement
of the clinical team as appropriate e.g. clinician, pharmacist. The NMC Standards state
that the registered nurse is ‘responsible for the initial and continued assessment of
patients who are self administering and have continuing responsibility for recognising
and acting upon changes in a patient’s condition with regards to safety of the patient
and others’ (NMC 2008, Standard 9).
To maintain standards and safety the registered nurse will:
1)
have undertaken education and be competent in SAM processes
2)
have developed skills in patient assessment for SAM
3)
be conversant with the contents of this guideline and the framework for SAM.
(Please refer to section 7.2 for further information on education of staff)
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6.1 Aims
Self-Administration of Medications has two broad aims:


Allows an uninterrupted continuation of the patient’s pre-admission medication
regime (where and when appropriate), using his or her own medications with
familiar packaging, thereby promoting continued independence.
Facilitates the development of an understanding of the actions of one’s own
drugs and correct self-administration to ensure maximum independence upon
discharge.
6.2 Patient Selection
It is anticipated that for many patients it may be suitable to maintain pre-admission
medication regimes during their in-patient stay in a Community Hospital by allowing
them to continue to self medicate.
For other patients, training towards independence on discharge may require more
Registered Nurse input and time for the educational aspects of SAM.
The following criteria will need to be adhered to:Inclusion criteria





Patients whom appropriate members of the multidisciplinary team (e.g.
Consultant, GP and Team Leader) deem to be suitable
Patients who are willing to assume responsibility for their medication
Patients who will assume responsibility for taking their medication at home
Patients who are on a stable medication regime
Wards with suitable facilities for storage and security of medication.
Exclusion criteria



Patients at imminent risk of deliberate self-harm.
Patient deemed unable to participate due to lack of capacity as defined under
the Mental Capacity Act (2005).
Patients who will not be self-medicating upon discharge.
Caution criteria



History of alcohol and detoxification.
Physical disabilities which prevent SAM.
Reduced cognitive capacity
Note: It is important not to automatically exclude patients who are confused if they are
expected to manage their own medicines when they go home. It may be possible to
establish a safe routine before they are discharged.
For patients supported by the Mental Health Team, advice should be sought from
a member of the team involved in their care before a decision is made to allow the
patient to self-administer.
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6.3 Patient Assessment
6.3.1 Initial Assessment
Once the patient’s suitability for SAM is decided, a full patient assessment is carried out
to determine the Level of supervision the patient requires. The assessment may be
undertaken by the registered nurse alone; with the patient/carer; or jointly with the
clinician and ward pharmacist. This will depend on individual patient needs.
At this point the patient should be given the Self-Administration of Medicines, Patient
Information Leaflet (Appendix 6) to read and be given the opportunity to discuss the
SAM process.
Completion of this assessment enables the healthcare professional to:

Obtain a medication history.

Assess the patient’s existing knowledge of his medications.

Confirm the patient’s ability to identify packaging and read labels.

Ensure the patient can open the containers.

Ensure the patient can recognise which drug is which.

Suitability of patients own medicines to be used in hospital.
To support this assessment process the Self-Administration of Medicines Assessment
and Consent Form (Appendix 1) must be completed by the Nurse and signed by the
patient and hospital doctor.
The NMC provides guidance on the Levels at which a patient can self-medicate (see
Table 1 below) (NMC 2008). The following must be clear on the Self Administration
Patient Assessment and Consent Form:
1)
The assessed Level of supervision required by the patient for SAM
2)
The person responsible for determining the Level
Table 1: Self Medication Levels – adapted from the NMC 2008
Level 1
The Nurse administers medicines to the patient providing a full
explanation of use.
The nurse is responsible for medication storage and the supervision
of the administration process ensuring the patient understands the
medications being administered.

Complete Medicines Reminder Sheet (Appendix 7) with
patient.

At the time of administration the nurse and patient discuss
what drugs should be taken at that time and the effect they
have on the body.

The nurse may prompt the patient to test his/her knowledge
of the drugs. This does not need to be undertaken during the
drug round.
Patient self-administers under nurse supervision
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Level 2
Patient self-administers under nurse supervision
Whilst the nurse is responsible for safe storage of medications the
patient self-administers the medications under supervision.

Complete the Medicines Reminder Sheet (Appendix 7) with
the patient, if not already completed.

The patient dispenses the medications under the supervision
of a nurse who unlocks the cabinet and checks that the dose
and the drug selected are correct.

Patient completes the Patient tick charts for regular
(Appendix 8) and “prn” (Appendix 9) medication

Level 3
The nurse can still provide information to the patient but
retains control over access to medications.
Patient self-administers medications independent
The patient demonstrates sufficient knowledge of his drugs and selfmedicates unsupervised, accessing medication from his bedside
cabinet independently.

If the patient is training towards independence, a member of
the Nursing Staff will check patient compliance and
medications at regular intervals. Patient may use tick charts
(Appendices 8 & 9) and Nurse will complete the Selfmedication compliance checklist. (Appendix 10)

Check the Prescription Chart at every drug round to ensure
all medicines have been taken and no “Nurse only
administration” medicines need to be given.

Check the drugs are prescribed on the hospital prescription
chart in the same dose, timing and method of administration
as labelled on the packaging.
6.3.2 Ongoing Assessment
Continuous assessment is required to ensure the patient maintains his/her level of
competence. The Self Administration of Medicines Patient Assessment and Consent
Form (Appendix 1) needs to be completed at least daily on Levels 1 and 2, and once
weekly on evaluation day for Level 3. A stepped approach is used (Level 1 – 3) to
enable patients to progress from full supervision to independence at discharge.
It is possible for patients to move down the Levels as well as up. If a patient’s condition
worsens he/she may have to move down the Levels or be temporarily removed from the
programme. Patients may be on different Levels for certain medications e.g. if they have
new medications added which require education towards self-medication whilst they
remain fully independent with their stable medications.
Any changes to the patient’s Level of Self-Administration of medication must be
recorded on the Variance Form (Appendix 5). This form should be used to document
the progress of the patient through the different stages of SAM as well as record any
problems the patient may encounter with the process.
For patients who are independent on admission, they may enter the programme at
Level 3.
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6.4 Patient Consent
The Safe and Secure Handling of Medicines: A Team Approach’ recommends written
consent is required prior to SAM in hospital (Royal Pharmaceutical Society 2005). SAM
is explained to the patient and a patient information sheet is provided (Appendix 6).
Relatives and carers/parents should be included if appropriate. If the patient wishes to
participate, he/she signs the consent section of the Patient Assessment Form (Appendix
1).
The patient consents to:

take part in SAM and

the use and disposal of his/her own medications whilst in hospital
The patient is informed that participation is voluntary and consent may be withdrawn at
any time.
6.5 Patient Education
The Level of supervision determined on initial assessment is discussed with the patient
and the nurse ensures the patient fully understands the implications of this.
For patients entering at Level 1 or Level 2, education on the dose, timing and method of
administration of medicines will be provided every time medications are dispensed.
Patients will also be given information on the actions of their medicines, their role in the
administration process and the potential to achieve greater control over the
administration of their drugs during their hospital stay.
6. 6 Prescribing, Storage and Dispensing Medications for SAM
6.6.1 Use of Patient’s Own Medications
Patient’s own medication can be used for SAM if the following criteria are met: These
are the same criteria as those for assessing patients own medicines on a medicines
management ward – (see Assessing Patients ~Own Medicines for Use on the Ward
Appendix 12)






The patient has consented to use his own medications whilst in hospital (See
Consent section of the Self Administration Assessment and Consent Form,
Appendix 1).
The packaging is intact and the expiry date has not been passed.
The label is clearly readable and contains the following information:
Name and strength of medication
Dose and frequency
Patient’s name
Date dispensed (must be within the last 6 months)
Name and address of dispensing chemist or doctor
The medicines are intact, dry and not broken, they appear to be of good quality and
match up with the label.
Eye drops and creams have been opened less than 4 weeks ago.
The packaging contains only those medicines identified on the label.
If the dosage on the label is not what the patient is currently taking (e.g. dose increased
following verbal telephone discussion with GP), the patient cannot self medicate that
medicine until it has been relabelled (see section 6.6 6 on prescribing which indicates
action to follow if dosage is altered).
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In addition the NMC has provided guidance on the use of patient’s own medicinal
products (see Appendix 13) (NMC 2008, Standard 5).
The assessment of the suitability of the Patient’s Own Drugs must be documented on
the Self Administration Assessment and Consent Form (Appendix 1).
6.6.2 Checking Patient’s Own Medications
Patient’s own medications can be checked by the registered nurse responsible for drug
administration at ward level, using the criteria outlined in section 6.6.1. If there is any
doubt, pharmacy staff (Ward pharmacist or technician) can be asked to assess the
suitability of the medications.
6.6.3 Refillable Compliance Aids/ Monitored Dose Systems/ Patients with
Disabilities
6.6.3.1 Refillable Compliance Aids
Certain patients, for example those with poor hand function, limited eye sight and/or
those with disabilities who live alone and have to cope with SAM on discharge can
achieve this by using refillable compliance aids. These allow a relative, carer or
pharmacy to dispense into the box on a daily or weekly basis. The drug boxes are
sectioned into days of the week. Each section has 4 compartments usually labelled for
breakfast, lunch, tea and bedtime.
For patients who are admitted with a refillable compliance aid, an individual patient
assessment needs to be carried out to determine the suitability for continued use of this
aid whilst in hospital. It is acknowledged that the independence of the patient, in the use
of this aid, must not be compromised whilst they are in hospital; however the aid allows
very limited checking of the medication contents against the aforementioned criteria for
patients’ own medications.
Only patients assessed at Level 3 SAM on admission may continue to use a refillable
compliance aid on the ward, providing no changes have been made to the medication
regime. In this case the patient is solely responsible for the contents of the device.
6.6.3.2 Monitored Dose Systems (commonly referred to as ‘blister packs’)
In order to aid compliance and give visual indication of whether doses have been taken
some patients in the community have their medications dispensed into tamper-evident
packs, known as monitored dose systems (MDS). These packs contain the daily doses
of the majority of the patient’s solid-dose medications. The MDS system can only be
used for SAM where all medication remains unchanged as individual medicines cannot
be identified for removal from the pack.
For patients who need to commence this system on discharge, a full assessment and
liaison with the relevant community pharmacist needs to take place. For further
guidance, refer to section 6.14 of the Policy for the Safe Ordering, Prescribing and
Administration of Drugs in Community Hospitals and Minor Injury Units
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6.6.3.3 NMC Medicines Management Standard 16
The NMC has provided recommendations on the use of aids to support compliance with
suggestions for other possible solutions (see Appendix 16) (NMC 2008, Standard 16).
6.6.4 Ordering and Secure Storage of Medications
For those patients on a medicines management ward follow the usual procedure for
ordering and replacing medicines as described in the procedure for medicines
management in community hospitals. A 28 day supply of medicines will be dispensed
for each patient.
Nursing staff should encourage all patients participating in the SAM process to inform
them of when their medicines need re-ordering. This will hopefully encourage the
patient to develop a routine for ordering their medication on discharge.
For patients on SAM, medications are stored in individual secure medication cabinets.
These should only contain medications clearly labelled for that patient.
Patients on Level 3 are provided with a key to the cabinet. Keys for cabinets of patients
at Levels 1 and 2 are retained by nursing staff. The registered nurse holds a master
key for each cabinet and a spare should be kept on the ward.
It is the responsibility of the patient and the discharging nurse to ensure any keys are
returned to the ward prior to discharge from hospital.
Where Patients Own Drugs (PODs) are not used for SAM they must be stored away
from the patient in a secure cupboard to ensure the patient does not become confused
and take them in error. They can be returned to the patient at discharge or destroyed if
no longer appropriate. Obtain and document the patients consent prior to destruction.
6.6.5 Medications omitted from inclusion in SAM
The following medications or circumstances need special attention within SAM.
 Controlled drugs will continue to be kept in the controlled drugs cupboard and
administered by nursing staff in accordance with the Trust policy for administration of
controlled drugs.
 Medications which have been recently introduced where the dose needs to be
stabilized, e.g. warfarin, may not initially be kept with the patient.
 Low molecular weight heparins and any injections that will not be continued on
discharge.
 Any drugs that are prescribed as a once only dose.
 Any drugs that require special storage conditions or refrigeration may not be stored
within the individual secure medication cabinets but may still be administered by the
patient if appropriate i.e. insulin.
6.6.6 Prescribing
6.6.6.1 Prescription Chart
All medications are prescribed on the hospital prescription chart (CHA 2272) in the
same dose, timing and method of administration as labelled on the packaging. If using
the patient’s own medications, medical/pharmacy staff need to be satisfied that the
details and drugs match up with the prescription chart.
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An entry should be made in the patient’s medical notes that the patient is self
medicating and the level at which they have been assessed. Any change in selfadministration status must be documented.
6.6.6.2 Newly prescribed medication
When a patient is prescribed a new drug the prescriber will complete an emergency
Patient Medication Label detailing the drug strength, dose and frequency. This
medicine, if in stock, can then be placed in the individual secure medication cabinet for
the patient to self-administer until a labelled supply is received from Pharmacy.
6.6.6.3 Discontinued drugs/altered dosage
When a drug is discontinued, or the dosage altered, the doctor will cancel or amend
the prescription in the usual way and must also alert the nurse so that she can
remove the item from the individual secure medication cabinet and advise the patient
accordingly.
6.6.6.4 Documentation/communication of alterations and additions
For all alterations and/or additions, the following documents, if being used by the
patient, will need to be updated by the nurse. A full explanation of the changes must be
given to the patient and any other relevant person, such as primary carer.

Patient’s Medicine Reminder Sheet (Appendix 7),

Patient Tick Charts (Appendix 8 and Appendix 9).

Self Medication Compliance Checklist (Appendix 10).
Upon receipt of the new drug/further supplies of a drug, the nursing staff must check it
against the Prescription. The nurse must then explain the drug to the patient and
ensure it is placed in the locked cabinet
6.7 Administration and Documentation
6.7.1 Administration
When patient’s own medications are administered by nursing staff, the administering
nurse must sign the prescription chart as usual.
If the patient is independently self-administering (Level 3), the prescription chart must
be checked by the nurse at each drug round in case any other items need to be
administered. For self-administered items, the nurses must tick/mark ‘SAM Level 3’
down the recording panels and verbally check with the patient if they have taken their
‘self medicated’ items. For Levels 1 and 2 and for other items administered by the
nurse, he/she must document in the usual way.
6.7.2 Medication Checks
Frequency and appropriateness of medication checks need to be decided on an
individual patient basis and in conjunction with the patient and the clinical team. The
decision and rationale must be documented within the nursing record. This may be
more appropriate for patients training towards independence. These checks are
documented on the Self Medication Compliance Checklist (Appendix 10), which will be
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kept inside the individual secure medication cabinets. As required drugs will be checked
to ensure the recommended dose over 24 hours has not been exceeded.
A drug error, when the patient takes the wrong number of tablets is recognised when a
discrepancy exists between the number of tablets remaining at the check and the
number that should have remained had the drug been administered correctly.
Discrepancies must be reported to medical staff and the nurse-in-charge immediately.
All drug errors which could potentially cause harm to a patient or where a significant
difference in the number of medications exists must be treated as major drug errors.
Minor discrepancies must be discussed with the patient and medical staff and the
patient must be reassessed to ensure it is safe for him/her to continue self-medicating.
All discrepancies and action taken must be documented in the nursing and medical
records and on the Trust’s Incident Reporting System
6.7.3 Essential Documents
To ensure good communication and maintain patient safety throughout each patient
admission to hospital, clear and careful documentation of the whole selfadministration process is paramount. The documentation required will be dependent
on the reason self medication is being undertaken for each patient and will be decided
on an individual patient basis by the appropriate team member (e.g. admitting nurse)
following a full patient assessment. A quick reference guide on essential documents is
provided in Appendix 11.
Documentation for each Level of Self-Administration of medications
For all Patients
Once the decision has been taken to try self administration of medicines with a patient
the following process should be followed.
Give the patient the Self Administration of Medicines patient information leaflet
(Appendix 6) to read, allowing them time to ask questions if needed
Complete the Self Administration of Medicines Assessment and consent Form
(Appendix 1) Patient, Doctor and Nurse must sign.
Determine the level of self administration to which the patient enters the process Levels
1,2 or 3.
Assess patients own medicines for suitability of use while in hospital. Follow the same
process used for assessing patients own medicines as detailed in the procedure for
medicines management in community hospitals. All medicines must be labelled with full
instructions as prescribed on the prescription chart. Until this has been checked and all
medicines labelled correctly the patient may not self-medicate.
When a patient is initiated on a new medicine during their hospital stay or the dose is
changed a new supply of that medicine with correct label must be ordered from
pharmacy to allow the patient to continue to self medicate.
It is acceptable for the prescriber to complete a label for medication taken from ward
stock to allow patients to commence treatment urgently and to continue to selfmedicate. A supply of blank labels can be obtained from pharmacy. The label should
meet the labelling requirements (see 6.6.1).
Level 1
Patient will have the following documentation:
 CHS Prescription Sheet CHA 2272
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
Medicines Reminder Sheet, completed with the patient. (Appendix 7)
Mark Level 1 on the prescription sheet and date commenced.
All medication in the patient’s medication locker must be fully labelled.
At each drug round the nurse will administer all medicines to the patient, signing the
administration section of the prescription sheet as usual. The nurse will show and
discuss each medicine with the patient. The medicine reminder sheet may be used to
help explain what the medicines are for and when to taken them.
Once the nurse feels the patient has a basic understanding of all of their medicines the
patient should be reassessed for level 2, completing the assessment and consent
form,(Appendix 1) as well as documenting on the Variance form (Appendix 5) the
reason for recommending the patient is ready to move to level 2.
Level 2
Patient will have the following documentation
 CHS Prescription sheet CHA2272
 Completed Medicine Reminder Sheet (Appendix 7)
 Patient Tick chart for regular medicines (Appendix 8)
 Patient Tick chart for when required medicines (Appendix 9)
Mark Level 2 on the prescription chart and date commenced.
At each drug round the nurse opens the patient’s bedside medication locker to allow the
patient to select the correct medicines.
The patient may use the Medicines Reminder Sheet (Appendix 7) as a prompt as well
as discussion with the nurse.
List all the Regular medicines (Appendix 8) and when Required medicines (Appendix 9)
the patient will be self administering on the Self Administration tick charts.
The patient should complete the tick charts for regular and when required medicines at
each drug round to show their understanding of correct timing of medicines.
The nurse will ensure that the correct medication is taken at each drug round and will
sign the administration of the prescription sheet as usual.
Encourage the patient to prompt when further supplies of medicines need ordering.
Once the nurse is confident that the patient is selecting the correct medicines at each
drug administration time the patient should be reassessed to move to Level 3. Complete
the assessment and consent form (Appendix 1) as well as the Variance Form (Appendix
5).
Level 3
Patient will need the following documentation





CHS Prescription sheet CHA 2272
Completed Medicines Reminder Sheet (Appendix 7)
Patient Tick Chart for Regular (Appendix 8) and ‘when required’ medicines
(Appendix 9) (may be used for patients working towards independence)
Self Medication compliance checklist (Appendix 10)
Key for bedside locker.
On the Prescription chart mark Level 3, Self-medicating and date commenced.
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List all the regular medicines (Appendix 8) and ‘when required’ medicines (Appendix 9)
the patient will be self administering on the Self Administration tick charts.
Although the patient is self-medicating independently the prescription chart must be
checked by the nurse at each drug round to make sure that all items prescribed for the
patient may be self administered.
Certain drugs must be administered and signed for by the nurse e.g.:



Controlled drugs,
Low molecular weight heparin injections or other injections that the patient will not
continue once discharged from hospital
Newly prescribed medicines for which a named patient supply has yet to be obtained
Once only medicines
If the patient is using the patient tick charts (Appendices 8 & 9), the charts must be
completed for all medication taken recording the date and time administered. These
charts must be checked by the nursing staff on a daily basis to ensure compliance.
The Self Medication Compliance Checklist (Appendix 10) must be completed by the
nurse before the patient commences on Level 3 self medication.
The quantity of each medicine must be recorded on the checklist.
Initially this checklist should be completed daily to establish an accurate picture of the
level of compliance of the patient.
Once results are consistent for 3 consecutive days, the frequency of carrying out the
checks can be reduced. This must be clearly documented on the Variance Form
(Appendix 5).and in the Patient Care Plan. Stock balances of all medicines in the
patient’s locker must be checked at least once every 7 days.
It is important to inform the patient that they must give at least 5 days notice to a
member of staff to obtain further supplies of their medicines from pharmacy.
6.8 Transfer of Patients
When patients are transferred to another ward any named medications in the individual
secure medication cabinets should be sent with them. However, before the patient can
continue SAM, a reassessment by staff on the receiving ward must be carried out.
6.9 Discharge of Patients
When a patient is to be discharged from hospital a Patient Discharge Summary Form
CHA 2592 (TTO form) must be written for him/her. The medications stored in his/her
individual secure medication cabinet may be suitable to be sent home as a TTO
although this must be confirmed by the prescriber and/or ward pharmacist. All
medications need to be itemised on the TTO form for the purposes of clear
communication with the patient’s GP. The patient must be discharged with at least 14
days supply of all their regular medicines plus a rewritten Appendix 7 together with
Appendices 8 & 9 to aid compliance with their self medication.
7.0 Risk Management Strategy Implementation
7.1 Implementation
The process can be implemented in Community Hospitals running a medicines
management system.
Education and training will be provided to each unit at roll out.
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7.2 Training and Support
For patients to self administer medications on a ward constitutes a major change in
Nursing practice across the whole of Peninsula Community Health services and will
require the following support and educational input:

Theoretical education on the SAM process and underpinning knowledge

Competency assessment of staff who will be undertaking patient assessments

Access to relevant documentation

Relevant equipment in place (individual secure medication cabinets)
The change process will need to be led by the ward manager with support and
educational input from the relevant pharmacist.
7.3 Dissemination
Once ratified this policy will be loaded to the intranet (read only).
Staff will be made aware of its existence through the weekly briefing email and the
Team Briefing.
Confirmation of receipt is not required for this procedural document.
7.4 Storing the Procedural Document
The signed procedural document will be stored centrally, Hard copies will be provided
for each ward, and the digital version will be available via the intranet.
8.0 Process for Monitoring Effective Implementation
SAM processes will be audited on a yearly basis on selected wards to ensure practice is
in line with these guidelines. The audit tool will include:
1)
2)
3)
4)
5)
information provision processes
consent processes
documentation processes
storage facilities and safe practices
medication incident reports relating to SAM
Audit results will be reported to the Quality and Patient Safety Committee.
9.0 Associated Documentation
This document references the following supporting documents which should be referred
to in conjunction with the document being developed.
NMC Standards for Medicines Management 2008
CIOS-CHS Records Management Policy - 1.6.2009 (adopted by PCH October 2011)
CIOS-CHS Policy for the Safe Ordering, Prescribing and Administration of Drugs in
Community Hospitals and Minor Injury Units, 2010 (adopted by PCH October 2011
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10.0 References
Policy for the Development and management of procedural documents. CIOS Community
Health Services. Available at http://cwlintranet/DocLibrary/default.asp
Altman IL, Wheeler R, Avery J (2002) Self-Administration of Medicines in Brighton
Hospital Pharmacist Vol 9, p305-307
Audit Commission (2001) A Spoonful of Sugar: Medicines Management in NHS
Hospitals London: Audit Commission
Department of Health (2000) Pharmacy in the Future – Implementing the NHS Plan
London: Department of Health
Hospital Pharmacists Group (2002) One-stop dispensing, use of patients’ own drugs
and self-administration schemes Hospital Pharmacist Vol 9, p81-86
Lowe CJ, Raynor DK, Courtney EA, Purvis J, Teale C (1995) Effects of self- medication
programme on knowledge of drugs and compliance with treatment in elderly patients
British Medical Journal vol 310, p1229-1231
Nursing and Midwifery Council (NMC) (2008) Standards for Medicines Management
London: NMC
Royal Pharmaceutical Society of Great Britain (2005) The Safe and Secure Handling of
Medicines: A Team approach
Department of Health Mental Capacity Act 2005 (c.9)
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APPENDIX 1
Self Administration of Medicines Assessment and Consent Form
Name:
D.O.B:
NHS Number:
CR Number:
PATIENT DETAILS
Consultant:
(Affix Patient Label)
GP:
Ward:
PATIENT CONSENT FOR SELF MEDICATION
Self-administration of medicines has been explained to me. I have read and understood the
information sheet ‘Self-Administration of Medicines’ and am willing to take part in the selfadministration programme on the ward or clinical area. I understand that I may withdraw from
the programme at any time by informing the nursing staff.
I consent to the use or disposal of my own medications as required (Please circle) YES NO
Consent (written/verbal)
Date:
Date:
Doctor’s Signature
Use continuation sheet
Use continuation sheet
PATIENT ASSESSMENT
Based on the questions below, please assess and indicate the level at which you
recommend the patient should self-medicate.
Questions to decide level of self-medication Indicate Yes (Y) or No (N) for each question
DATE:
Has SAM been explained to the patient and the
patient information leaflet been given?
Has the patient read and understood the leaflet
explaining self-medication?
Has patient consent been obtained?
Does the patient self administer medication at
home?
Weekly assessments
Can the patient open the containers and take
their medicines?
Can he/she read the labels on the containers?
Daily assessments – document once daily on prescription chart as Level 1, 2 or 3
Is the patient competent to make decisions
about taking their medication?
Does the patient understand the purpose of
his/her medications?
Does the patient understand the dosage, timing
and any special instructions?
LEVEL:
Name & Signature of Assessing Health
Professional
Key given to patient
Date
Signature
Date
Signature
(Level 3 Only):
Key returned :
Medication Assessment
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Patient’s own medication assessed as suitable for use on
the ward (See Appendix 12)
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Yes/No
(please circle)
29 November 2011
Self Administration of Medicines Assessment and Consent Form - Continuation Sheet
Name:
D.O.B:
NHS Number:
CR Number:
PATIENT DETAILS
Consultant:
GP:
Ward:
(Affix Patient Label)
PATIENT ASSESSMENT
Based on the questions below, please assess and indicate the level at which you recommend the patient should self-medicate.
Questions to decide level of self-medication
Please indicate Yes (Y) or No (N) for each question
DATE:
Has SAM been explained to the patient and the patient information leaflet been
given?
Has the patient read and understood the leaflet explaining self-medication?
Has patient consent been obtained?
Does the patient self administer medication at home?
Can the patient open the containers and take their medicines?
Can he/she read the labels on the containers?
Is the patient competent to make decisions about taking their medication?
Does the patient understand the purpose of his/her medications?
Does the patient understand the dosage, timing and any special instructions?
LEVEL:
Name & Signature of Assessing Health Professional
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APPENDIX 2
SAM Quick Reference Guide
Level 1:
Level 2:
Level 3:
SELF ADMINISTRATION LEVELS
The nurse administers medicines to the patient providing a full explanation of the use
of all medicines.
Medications will be kept in the patient’s individual secure medication cabinet. Medicines
will be fully labelled with all dosage instructions.
Patient self-administers under nurse supervision.
Medications will be kept in the patient’s individual secure medication cabinet. The patient is
responsible for dispensing them under the supervision of a nurse who unlocks the individual
secure medication cabinet and checks that the dose and the drugs selected are correct.
Patient self-administers medications independently.
The patient is assessed as competent to self-medicate unsupervised, accessing
medication from the individual secure medication cabinet independently using the key.
Informs nursing staff when further supplies of medicines are required.
APPENDIX 3
SAM Quick Reference Guide
Ordering, Prescribing, Administration & Documentation
Ordering :
 All medication in the patient’s medication locker must be fully labelled, ensuring that the dosage
instructions for each medicine are the same as those on the prescription chart.
 A 28 day supply of all medicines will be supplied.
Prescribing:
 All medication for the patient must be prescribed on the prescription sheet. Any changes to
medication must be communicated to the nursing staff and patient to ensure that all relevant
SAM paperwork is updated.
Administration:
 Where a patient is self-administering (Level 3) the prescription chart should be checked by the
nurse on each drug round in case any items need to be administered by a nurse, or any new
items have been prescribed.
 Level 2 the nurse opens the patient’s medication locker and the patient selects, under the
supervision of the nurse, the correct medicine.
 Level 1, the Nurse administers the medicine to the patient.
Documentation:
 If a nurse is required to administer a patient’s medications then the nurse should put a circle
around her initials after signing on the prescription chart.
 For self-administered items, the nurses will write ‘SAM Level 3’ down the recording panels.
Administration of other items will be documented in the usual way.
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APPENDIX 4
SAM Flow Chart
Patient is suitable for SAM
Obtain consent and carry out patient assessment to determine Level
(Self Administration Assessment & Consent Form - Appendix 1)
Has patient consented to use his/her own drugs?
(Self Administration Assessment & Consent Form - Appendix 1 )
No
Yes
Obtain Medications from pharmacy
suitable for SAM (With full details and
instructions)
(See Section 6.6.6 – Prescribing)
Assess Patient’s Own Medications
for suitability
(POD Flowchart- Appendix 12)
Educate patient on the implications of the Level of supervision they require and
provide access to the bedside locker if Level 3
Level 1 and 2 (Requiring Educational Input)
 Provide Medicine Reminder Sheet
(Appendix 7) & Patient Tick Charts
(Appendices 8 & 9 ) to the patient.
 Provide required Level-specific
educational input at each drug round
 Complete Compliance checklist (SelfMedication Compliance Checklist – Appendix 10 )
Level 3 (Fully Independent)
 Check Prescription sheet at each
drug round for non-SAM items
 Provide Medicine Information
Card and Patient Tick Charts.
 Compliance checklist is optional
(Assessor or patient dependent)
Daily Reassessment to determine current or changing Level
(Record variance on Appendix 4)
Documentation:
 Consent to SAM & use of own medicines
 Level of supervision required
 Daily reassessment
 Assessment of Patients Own
Medications
 Compliance checklist
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Level 1 - The nurse administers medicines to the patient
providing a full explanation of use of medicines.
Level 2 - Patient self-administers under nurse supervision.
Level 3 - Patient self-administers medications independently.
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APPENDIX 5
VARIANCE (Please record reason(s) for change of Level)
Name:
D.O.B:
(Affix Patient Label)
NHS Number:
CR Number:
Ward:
GP/Consultant:
Date Time Reason for Variance
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Name & Signature
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VARIANCE (Please record reason(s) for change of Level)
Name:
D.O.B:
(Affix Patient Label)
NHS Number:
CR Number:
Ward:
GP/Consultant:
Date Time Reason for Variance
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Name & Signature
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APPENDIX 6
SELF-ADMINISTRATION OF MEDICINES
PATIENT INFORMATION SHEET
A self-medication facility is available on this ward to enable patients,
where possible, to be responsible for taking some or all of their own
medicines.
Self-medication is NOT COMPULSORY and you need not feel that you
have to administer your own medicines.
If you decide you would like to take part, a member of staff will discuss
exactly what self medication involves and the possible benefits for you.
You will be asked about all your current medicines and these will be
checked by the nurse or pharmacist.
Your medicines will be kept in a locked cabinet in your room. Whether
you have access to this or not depends upon the level of support you
initially need. If you usually administer your own medicines at home,
you should be able to fully self-medicate before you leave the hospital.
Your own medicines from home may be used if suitable. Any other
medicines you require will be obtained for you from the hospital
pharmacy.
All your medicines will be clearly marked with your name, the name of
the medicine and instructions on how to take them.
If at any time you have any questions concerning self-medication
please contact the nursing staff who will be happy to help.
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PLEASE REMEMBER

It is your responsibility to keep your medications safely locked in
the cabinet and keep the key in a safe place.

Do not exceed the stated dose.

If you forget the number of tablets or when to take them, or if you
have any questions please ask one of the nursing staff.

Remember that, if not used properly, medicines can be
dangerous.

If anyone tries to take your medicines please contact the nursing
staff immediately.

Before you go home your medicines will need to be checked.
Please allow the staff time to do this.

Please remember to return your key to nursing staff before you go
home.
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APPENDIX 7
MEDICINES REMINDER SHEET - Times to Take your Medication
This is not a Prescription – For Patient Guidance Only
Name
Name of Medicine
Written by (Print Name)
Please take this sheet with you when you visit your Doctor, Nurse or Pharmacist
NHS No
Dose
Times to be taken
What I take this
medicine for
Checked by (Print Name)
Signature:
DOB
Signature:
Yellow booklet with latest INR results to be supplied for patients on warfarin.
Record cards, instructions and information leaflets to be supplied for patients on methotrexate or lithium.
Total no. medicines (including any listed on the back of this form)
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Notes
How to take the medicine
(Eg with food, take only when needed,
when to stop taking etc)
Side effects (eg constipation)
Date:
MEDICINES REMINDER SHEET - Times to Take your Medication (continuation sheet)
This is not a Prescription – For Patient Guidance Only
Name
Name of Medicine
Please take this sheet with you when you visit your Doctor, Nurse or Pharmacist
NHS No
Dose
Times to be taken
What I take this
medicine for
Special Notes
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DOB
Notes
How to take the medicine
(Eg with food, take only when needed,
when to stop taking etc)
Side effects (eg constipation)
APPENDIX 8
SELF ADMINISTRATION TICK CHART – Regular medicines
NHS/CR NUMBER:
PATIENT NAME:
DRUG, DOSE & FREQUENCY
WARD:
DATE
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
Written by:
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Signature:
Checked by:
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Signature:
29 November 2011
PATIENT TICK CHART FOR REGULAR MEDICINES
SELF ADMINISTRATION TICK CHART – Regular medicines
PATIENT NAME:
DRUG, DOSE & FREQUENCY
NHS NUMBER:
CR NUMBER:
WARD:
DATE
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
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APPENDIX 9
PATIENT TICK CHART FOR ‘AS REQUIRED’ MEDICINES
SELF ADMINISTRATION TICK CHART – ‘As Required’ Medicines
PATIENT NAME:
DRUG, DOSE & FREQUENCY
NHS NUMBER:
CR NUMBER
WARD:
DATE
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
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PATIENT TICK CHART FOR ‘AS REQUIRED’ MEDICINES
SELF ADMINISTRATION TICK CHART – ‘As Required’ Medicines
PATIENT NAME:
DRUG, DOSE & FREQUENCY
NHS NUMBER:
CR NUMBER
WARD:
DATE
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
08.00
10.00
12.00
14.00
18.00
22.00
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APPENDIX 10
SELF-MEDICATION COMPLIANCE CHECKLIST
Sheet No….. of……
PATIENT NAME:
WARD:
NHS / CR NO:
Drug Name &
Quantity Supplied
Date
Time
REGULAR PRESCRIPTIONS
Predicted
Amount
1
Actual
Amount
Predicted
Amount
2
Actual
Amount
Predicted
Amount
3
Actual
Amount
Predicted
Amount
4
Actual
Amount
Predicted
Amount
5
Actual
Amount
Predicted
Amount
6
Actual
Amount
Predicted
Amount
7
Actual
Amount
Predicted
Amount
8
Actual
Amount
Predicted
Amount
9
Actual
Amount
Predicted
Amount
10
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Actual
Amount
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SELF-MEDICATION COMPLIANCE CHECKLIST
Sheet No….. of……
PATIENT NAME:
WARD:
NHS / CR NO:
Drug Name &
Quantity Supplied
Date
Time
REGULAR PRESCRIPTIONS
Predicted
11 Amount
Actual
Amount
Predicted
12 Amount
Actual
Amount
Predicted
13 Amount
Actual
Amount
Predicted
14 Amount
Actual
Amount
Predicted
15 Amount
Actual
Amount
AS REQUIRED PRESCRIPTIONS
Number
Issued
1
Actual
Amount
Number
Issued
2
Actual
Amount
Number
Issued
3
Actual
Amount
Number
Issued
4
Actual
Amount
5
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Number
Issued
Actual
Amount
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APPENDIX 11
Quick Reference Guide on Essential Documentation
To ensure good communication and maintain patient safety throughout each patient
admission to hospital, clear and careful documentation of the whole self-administration
process is paramount. The documentation required will be dependent on the reason self
medication is being undertaken for each patient and will be decided on an individual patient
basis by the appropriate team member (e.g. admitting nurse) following a full patient
assessment. Read the following for guidance.
Minimal Documentation Required for Patient who is assessed as SAM Level 3
(Already self medicating at home – minimal medication changes, short stay, maintain uninterrupted
continuation of pre-admission medication regime)
Self Administration Assessment and Consent Form – Appendix 1
Additional Documentation Required for Patient who is assessed as SAM Level 1 or 2
(Those patients who will be self administering following discharge but need additional educational
and practice input to enable this to occur – new complex regimes, those assessed as requiring
medication checks)
Medicine Reminder Sheet – Appendix 7
Patient Tick Charts – Appendices 8 & 9
Self Medication Compliance Checklist – Appendix 10
Bedside Reference Required by Staff
SAM Quick Reference Guide – Appendix 3
Quick Reference Guide on Essential Documentation – Appendix 11
Information Required by Patient
SAM Patient Information Sheet – Appendix 6
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Appendix 12
Assessing Patient’s Own Medicines for use on the Ward.
The following conditions must be met for Patients Own Drugs to be used on the
wards
All medicines must be:
 Labelled with the patients name
 Labelled with Instructions that correspond with the prescription chart
 Dispensed within the last 6 months
 In good condition
 In date
Tablets
Liquids
Mixed or loose tablets should not be used
Must be in original bottle
Mixed batches should not be used
Must be in foil strips or original containers
Creams/Ointments
Must be opened less than 4 weeks ago
Eye Drops
Must be opened less than 4 weeks ago
Fridge items
Must have been stored correctly
Dosette boxes
Store excess stock in fridge
Do not use. (impossible to verify contents)
Blister packs
Controlled Drugs
If possible check with pharmacist before using.
Use only if above conditions met
Enter in “Patients Own” CD register
Inhalers
Use a separate page for each item
Must be reasonably full (if not, re-order)
If you have ANY doubts about a patient’s own medication,
DO NOT USE THEM!
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Appendix 13
The (Relevant) NMC Standards for Medicines Management (2008)
The NMC Standards for Medicines Management relevant to SAM
Standard 5 - Dispensing
Registrants may use patient’s’ own medicines in accordance with the guidance in this booklet
Standards for medicines management.
The NMC welcomes and supports the self-administration of medicinal products and the
administration of medication by carers wherever it is appropriate.
The use of patient’s’ own medicinal products in any setting
Where patients have their own supply of medicinal products, whether prescribed, over the
counter (from a pharmacy or supermarket/shop), complementary therapy, herbal preparation
or homely remedy such as paracetamol, the registrant has a responsibility to:
 ask to see the medicinal products
 check for suitability of use
 explain how and why they will or won’t be used
 establish if they are prescribed
 ascertain if they meet the criteria for use.
These medicinal products including Controlled Drugs remain the patient’s property and must
not be removed from the patient without their permission and must only be used for that
named individual.
The registrant has a responsibility to document in the patient’s notes when a patient refuses
consent:
 to use their own medicines.
 to dispose of their own medicinal products no longer required.
 to dispose of their own medicinal products not suitable for use.
 when in the hospital or care home setting to send their own medicinal products home
with a relative or carer.
Storage of patients’ own medicinal products
As a registrant you have the following responsibilities:
 to ensure that suitable facilities are provided to store patients’ own medicinal products
for their safe storage
 to assess patients on a regular basis using local polices to ensure that the individual
patient is still able to self-administer
 to document issues relating to storage in their records.
 the medicines cabinet/locker is kept locked and that the master key is kept secure.
 if the patient is self-administering, consent is obtained from the patient to keep the
individual medicines cabinet/locker locked and the key secure with the patient.
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 if a patient moves to another bed, to another ward/room or is discharged the patient’s
medicinal products are transferred with the patient.
 in a hospital setting, best practice indicates that stock medicines should not be placed in
the patient’s locked cabinet/locker as they are not labelled for that individual patient.
Administering medicines using the patient’s own supply in the hospital/care home
setting.
When administering medicines from the patient’s own supply the registrant must check the
medicines in the locked cabinet/locker with the prescription chart and use only those medicines
belonging to that named patient.
If a supply is not available medicines belonging to another patient must not be used.
For further guidance on the use of patients’ own medicinal products including discharge and
checking medications ‘to take home’ (TTO’s) see Annexe 3. For self-administration of
medicines see Standard 9 of this document Self-Administration of medicines.
One Stop Dispensing
In some hospitals a system of One Stop Dispensing is in operation and local policies should be
developed for this using the guidance for patients’ own medicinal products as stated under
Standard 5 of this document.
Guidance
One-stop dispensing is a system of administering and dispensing medicinal products adopted
in hospitals throughout the UK (Audit Commission Report: A Spoonful of Sugar 2002 – The
Right Medicine (Scottish Executive 2002). It involves using the patient’s own medicinal
products during their stay in hospital, either those dispensed by a community pharmacy or by
the hospital pharmacy or both, providing they contain a patient information leaflet and are
labelled with full instructions for use. Supplies are replenished should the supply run out whilst
in hospital or when any new items are prescribed. Patients are discharged with a supply of
medicinal products as agreed locally.
In one-stop dispensing medicinal products are dispensed once only on or during admission
ready for discharge. Registrants should check that the medication handed to the patient on
discharge is as per the discharge prescription, as medicines may be altered / stopped during
hospital admission. If a particular medicine has been stopped during admission and is not to
be restarted on discharge, the patient must be informed. The ward pharmacist is a useful
resource for advice.
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APPENDIX 14
NMC Standard 9 - Standards for Practice of Administration of Medicines
As a registrant you are responsible for the initial and continued assessment of patients who
are self-administering and have continuing responsibility for recognising and acting upon
changes in a patient’s condition with regards to safety of the patient and others.
The NMC welcomes and supports the self-administration of medicinal products and the
administration of medication by carers wherever it is appropriate. Registrants may assess the
patients as suitable to self-administer medicinal products both in the hospital and primary care
settings.
Duty of care relating to using patients’ own medicinal products.
Guidance
At all times the registrant jointly with other health care professionals has a duty of care to the
patient to ensure that only medicinal products which are prescribed and meet the required
criteria are used by the patient.
Where self-administration of medicinal products is taking place, you should ensure that records
are maintained appropriate to the environment in which the patient is being cared for. The
Mental Capacity Act 2005 requires all those working with potentially incapacitated people to
assess the individual's capacity at a particular moment about a particular decision/issue. All
patients should be assessed on a regular basis using local policies to ensure that the individual
patient is still able to self-administer and this should be documented in their records.
Patients can be assessed for suitability at the following Levels:
Level 1
The registrant is responsible for the safe storage of the medicinal products and the supervision
of the administration process ensuring the patient understands the medicinal product being
administered.
Level 2
The registrant is responsible for the safe storage of the medicinal products. At administration
time the patient will ask the registrant to open the cabinet/locker. The patient will then selfadminister the medication under the supervision of the registrant.
Level 3
The patient accepts full responsibility for the storage and administration of the medicinal
products. The registrant checks the patient’s suitability and compliance verbally.
The Level should be documented in the patient’s notes.
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Guidance
Where patients consent to self-administration of their medicines the following points should be
considered:
1. Patients share the responsibility for their actions relating to self-administration of their
medicines.
2. Patients can withdraw consent at any time.
3. The pharmacy will supply medicines fully labelled, with directions for use, to every patient
who is involved in self-administration.
Information given and supervision should be tailored to individual patient need.
The following information should be provided to a patient before commencing selfadministration:
- the name of the medicine
- why they are taking it
- dose and frequency
- common side effects and what to do if they occur
- any special instructions
- duration of the course or how to obtain further supplies
The registrant must ensure that the patient is able to open the medicine containers or is
offered assistance e.g. compliance aid.
Whilst the registrant has a duty of care towards all patients the registrant is not liable if a
patient makes a mistake self-administering as long as the assessment was completed as the
local policy describes and appropriate actions were taken to prevent re-occurrence of the
incident.
Guidance on exclusion criteria for self-administration of medicines can be found in 6.2 Patient
Selection.
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APPENDIX 15
Standard 10 - Self-Administration – Children and Young People Environments
In the case of children, when arrangements have been made for parents/carers or patients to
administer their own medicines prior to discharge or rehabilitation, the registrant should
ascertain that the medicinal products have been taken as prescribed.
Guidance
This should preferably be done by direct observation but when appropriate also by questioning
the patient/parent/carer. The administration record should be initialled and ‘patient selfadministration’ documented.
The administration of medicinal products by parents/carers to their children must be carefully
controlled.
There is the potential for inadvertent omission of doses or administration of extra doses unless
there is clear communication and documentation.
Parents/carers can be encouraged to administer to their children in whatever setting when this
is
appropriate to the clinical condition of the child and when the registrant has assessed that the
parent/carer is competent to do so. In a hospital setting the registrant should provide the
medicinal product from the appropriate storage and supervise administration.
Unsupervised administration to children
Some parents/carers may administer to their children unsupervised if this has been agreed
with the Registrant in Charge and if the medicinal products are stored in an appropriate secure
locker. Responsibilities of the registrant and parent/carer must be specifically agreed and
approved by the Registrant in Charge and agreed under local policies. Arrangements must be
made for holding keys to the locker and for ensuring their return on discharge and that any
medicinal products remaining are supplied for discharge (if appropriately labelled and checked)
or returned to the pharmacy.
The employing organisation should ensure appropriate clinical governance structures are in
place.
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APPENDIX 16
NMC Standard 16 - Aids to Support Compliance
Registrants must assess the patient’s suitability and understanding of how to use an
appropriate compliance aid safely.
Guidance
Before considering the use of compliance aids the registrant should explore with the patient
other possible solutions, for example reminder charts, large print labels, non-childproof tops.
Self-Administration from the dispensed containers may not always be possible for some
patients. If an aid to compliance is considered necessary, careful attention should be given to
the assessment of the patient’s suitability and understanding of how to use an appropriate aid
safely. Ideally a locally recognised assessment tool should be used.
However, all patients will need to be regularly assessed for continued appropriateness of the
aid. Ideally, any compliance aid, such as a monitored dose container or a daily/weekly dosing
aid, should be dispensed, labelled and sealed by a pharmacist. The sealed compliance aids
are generally referred to as monitored dosage systems.
Where it is not possible to get a compliance aid filled by a pharmacist, you should ensure that
you are able to account for its use. The patient has a right to expect that the same standard of
skill and care will be applied by you in dispensing into a compliance aid as would be applied if
the patient were receiving the medication from a pharmacist. This includes the same standard
of labelling and record keeping.
Compliance aids, which can be purchased by patients for their own use, are aids that are filled
from containers of dispensed medicines. If you choose to repackage dispensed medicinal
products into compliance aids, you should be aware that their use carries a risk of error. You
should also be aware the properties of the drug might also change when repackaged and so
may not be covered by their product licence. Your employer needs to be aware of this activity
and it should be covered by a SOP (Standard Operating Procedure) The NMC would
recommend that you confirm the appropriateness of re-packaging dispensed medicinal
products with the community pharmacist who dispensed the medicines. You also need to
consider how the patient will cope with medicines that cannot be included in compliance aids.
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Equality and Human Rights Impact Assessment (EDHRIA)
Part One – Initial Assessment Screening Tool
Name of the policy or
methodology:
Guidelines for Patient Self-administration of
medicines (SAM)
Details of person completing the EDHRIA
Name
Rosalind Palmer
Job Title
Pharmaceutical Adviser
Directorate/Programme Board
Clinical Governance
Telephone Number
01209 881674
1.
Identify the policy or methodology aims
What are the main aims, purpose and outcomes of the policy or methodology?
 Maintain patient independence in self-administration of medication where
medication changes are minimal.
 Improve patient knowledge and skills where gaps are identified, thereby
increasing independence and concordance on discharge.
 Possibly reduce re-admission due to treatment failure caused by noncompliance.
 Highlight medication related problems prior to discharge e.g. poor eyesight or
complex packaging/medication regimes, understanding of labelling.
 Maintain independence and maximum therapeutic benefit for those patients
who are on complex timed regimes that do not correspond with the timings of
the traditional drug round e.g. Parkinson’s disease.
Does it relate to our role as a service provider and/or an employer?
Yes it supports the recommendations laid out in the Care Quality Commissions
Essential Standards of Quality and Care, March 2010, Outcome 9: Management
of medicines.
Providing personalised care through the effective use of medicines by supporting
and reminding patients to self-administer their medicines independently where
they are able and wish to do so by minimising the risk of incorrect administration.
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2. Assess the likely impact on human rights and equality
Use this table to check if the policy or methodology:
 could have a negative impact on human rights and/or on any of the equality groups, or
 could have a positive impact on human rights, contribute to promoting equality, equal opportunities or improve relations.
It is not necessary to complete each box. Refer to the form guide point 2 for further details (LINK to website).
Pregnancy &
Maternity
Marriage & Civil
Partnership
Gender
Reassignment
Age
Religion or belief
Sexual
Orientation
Disability
Gender
Race
Equality & Diversity Protected Characteristics
General
Human Rights
 Right to life e.g. decisions about life-saving treatment, deaths through
negligence in hospitals and care homes
 Right not to be tortured or treated in an inhuman or degrading way
e.g. dignity in care, abuse or neglect of older people or people with
learning disabilities.
 Right to respect for private and family life e.g. respecting lgb
relationships, confidentiality
 Right to freedom of thought, conscience and religion e.g. respect for
cultural and religious requirements
 Right to freedom of expression e.g. access to appropriate
communication aids
 Right to freedom of assembly and association e.g., right to
representation, to socialise in residential care settings
 Right to education e.g. access to basic knowledge of hygiene and
sanitation
 Right to liberty e.g. informal detention of patients who do not have
capacity
 Other types of discrimination e.g. employment, harassment, differential
health outcomes
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3.
How does it impact on people’s Equality, diversity and human rights?
Using the table above, explain anticipated impacts. If a full EDHRIA is recommended, you can
summarise the impacts at this point and in more detail in the full EDHRIA.
Could people be impacted negatively? Could the policy or methodology result in inequality or
discrimination.
No the guidelines support staff in ensuring that where patients are willing and able to administer their
own medicines while in hospital they are able to do so safely. A standard set of criteria are used to
assess each patient.
Could this policy or methodology result in positive impacts on people’s equality, diversity, human
rights? Could it present opportunities to promote equality?
Yes, By supporting patients in administering their own medicines it promotes independence whilst in
hospital, provides patients with a choice about when and how to take their medicines. These
guidelines also support staff in informing patients about their medicines, providing them with more
knowledge of the medicines they are taking.
4.
Recommendations
Is a full EDHRIA recommended? If not, give reasons
No- These guidelines have a positive impact on people’s equality, diversity and human rights and are
in line with the recommendations for patient care issued by CQC.
Details of person completing the EDHRIA
Name
Rosalind Palmer, Pharmaceutical Adviser
Signed ……………………………………………………… Date: …………………………………
Approval and sign-off
Head of function/business director
Name
Helen Newson, Director of Nursing & Professional Practice
Signed ……………………………………………………… Date: …………………………………
Name
EDHRIA sign-off by CHS Equality &
Diversity Sub Committee
Signed ……………………………………………………… Date: …………………………………
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Full Equality and Human Rights Impact Assessment (EDHRIA)
This section is only completed if a full EDHRIA is recommended from the Initial Screening Tool
Part Two – Evidence Gathering and Involvement
Refer to form guide points 6 – 9 for further details (LINK TO WEBPAGE).
6. How does it impact on people’s rights? Consider the evidence and research. Refer to
your responses under Item 2 to ensure that all aspects are covered.
Could people’s equality, diversity, human rights be impacted negatively? Could the policy or
methodology result in inequality or discrimination? If yes, what is the evidence?
Evidence
Actions that could reduce negative
impacts
Could this policy or methodology result in positive impacts on people’s equality, diversity, human
rights? Could it present opportunities to promote equality and diversity?
Evidence
Actions that could increase positive
impacts
7.
Gaps in evidence
Are there any gaps in the evidence? If so, provide details.
Is this evidence required and if so, how can it be obtained?
(e.g. consultation with specific groups)
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8.
Involvement of people who use services and staff
Have you involved or will you involve people who use services, staff and other stakeholders?
Target group
Summary of involvement
People who use
services
Staff
Other stakeholders
9.
Listening to what people say
Have you made any changes to policy or methodology as a result of involvement of staff and
people who use services? List the major changes made or planned.
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Part Three – Actions and Outcomes
See Guidance points 10 & 11 for help.
10.
Monitoring and review of the EDHRIA
Give details of the monitoring arrangements. How will the impact of the policy or methodology be
monitored, who will do this and when?
Review date
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Action
Draft V1 CHS EDHRIA Form
Lead
Time
scale
Success measure
Outcome
7
Marriage & Civil
Partnership
Pregnancy & Maternity
Gender Reassignment
Age
Religion or belief
Sexual Orientation
Disability
Gender
Race
Human Rights
11.
Action Plan and Outcome Report
Details of person completing the EDHRIA
Name
Signed ……………………………………………………… Date: …………………………………
Approval and sign-off
Head of function/business director
Name
Signed ……………………………………………………… Date: …………………………………
Name
EDHRIA sign-off by CHS Equality &
Diversity Sub Committee
Signed ……………………………………………………… Date: …………………………………
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