SH CP 168

Self-Administration of Medicines
Procedure
Version: 3

Summary: Procedure for when a patient takes responsibility for

taking own medicines as prescribed by a doctor and
dispensed by a pharmacy in line with NICE guidelines.

Keywords (minimum of 5): Self-administration; patient medicines; own medicines,

(To assist policy search engine) procedure, inpatients, wards.

Target Audience: Nurses, MHPs, Pharmacists, Pharmacy Technicians,

Medical Staff.
Next Review Date: January 2020

Approved & Ratified by: Medicines Management Date of meeting:

Committee 21 November 2018

Date issued: January 2019

Author: Kathryn Lacey, Clinical Pharmacist

Accountable Executive Lead: Karl Marlowe, Medical Director

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SH CP 168 Self-Administration of Medicines Procedure
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 Version Control
Change Record

Date Author Version Page Reason for Change

Sept Anne Leitch 1 Transfer to SHFT format
2014 Tim Coupland
Nov 17 Nicola Bennett 2 3 New contents list
4 Change to title of section 3. Point 3.1 removed from version
1. Numbering changed in section 3
5 3.3 in version 1 moved to 5.1 in version 2. New section 4
added. Change of name and number for section 4 in version
1 to section 5 in version 2
6 Additional wording added to section 5. Change of section
number 5 in version 1 now section number 6 in version 2
7 Change of section number 6 in version 1 now section
number 7 in version 2. Additional wording added to section
7. Change of section number 7 in version 1 now section
number 8 in version 2
8 Change of section number 8 in version 1 now section
number 9 in version 2. Change of section number 9 in
version 1 now section number 10 in version 2. Change of
section number 10 in version 1 now section number 11 in
version 2. Change of section number 11 in version 1 now
section number 12 in version 2
Sept Kathryn Lacey 3 Through Rewrite of the document in view of the implementation of
2018 out self-medication on community rehabilitation wards.
Nov Steve Mennear 3 Through Changed to a procedure, wording changed. Self-
2018 out administration (SAM) added throughout
Physical health guidelines reference removed
7 Added information about partial self-administration
Title changed from Self Administration Guidelines

Reviewers/contributors

Name Position Version Reviewed &

Date

Nicola Bennett Associate Director of Nursing Version 1 September

2017
Kathryn Lacey Clinical Pharmacist Nov 2017, 2018

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SH CP 168 Self-Administration of Medicines Procedure
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 Contents

Page

1. Introduction 4
2. Requirements 4
3. Levels of self-administration 6
4. Monitoring/Evaluation 7
5. Safety and Accountability 7
6. Nicotine Replacement Therapy 8
7. Compliance Aids 8
8. Monitoring Compliance 8
9. Related Policies 8
10. References 8

Appendices
A1 Self-Administration assessment form 9
A2 Patient Agreement Consent Form 10
A3 Medication reminder card 11
A4 Sample Tablet count form 13
A5 Sample Self Administration Monitoring 14

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 Self-Administration of Medicines Procedure

1. Introduction

Where possible and as long as it is safe patients in hospital should be encouraged to self-
administer their own medication.

The aims of the self-administration of medicines (SAM) are to;

 Empower those competent in taking their own medication to continue to do so if

appropriate.
 Encourage self-care in a safe environment whilst minimising the risk of incorrect
administration.
 Establish any support systems which will be required by the patient after discharge
 Increase understanding and concordance with medication regimes, hence reducing
medication related admissions.

2. Requirements and Implementation

Assessment of the patient

Self-administration of medicines (SAM) will not be appropriate for all patients. The Multi-
Disciplinary Team (MDT) must ensure that the patient has the capacity to be involved in
the process.

Each patient should be assessed for their ability to self-administer their prescribed
medicines by a nurse or member of the medicines management team using the form in
appendix 1. The procedure should be fully discussed with the patient. Consent to
participate must be documented on the consent form (Appendix 2). The assessment must
take into account religious, cultural and spiritual aspects of the person’s life, their beliefs
and any learning disability, visual/ communication disability, manual dexterity or
communication issues.

There are four levels of self-administration of Medicines (SAM).It is possible to start the
process at any level; patients may also bypass levels if appropriate.

For patients detained under the Mental Health Act issues associated with part 4 of the Act
continue to apply if self-administering.
If it is decided that either the patient is not suitable at this time or does not consent then
this should be documented appropriately. This should be reviewed at a later date.

Ward/unit practicalities

Each ward /unit must look at the feasibility of implementing SAM. Each care environment
must have safety measures in place to allow safe practice of SAM to be carried out.

Risks of medication misuse should be minimised but if it cannot be ensured SAM should
be limited to level 1. This should be re-evaluated regularly depending on the ward
environment and the patient’s mental state and capacity.

Individual patient bedside lockers for the safe, secure storage of medication should be
available; if these aren’t available then self-administration is limited to Level 1.

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 Medication supplies

Patients self-administering their medicines must have their own individually dispensed
supply. The medicines must be assessed as suitable by a member of the medicines
management team. The amount dispensed varies according to the level of self-
administration. It is important to assess how much medication can be safely dispensed
depending on the risk of misuse.
Any discontinued medication should be removed from the locker.

Documentation

Where care plans are used they must clearly indicate the aims and education required by
each patient who is self-administering.
Care plans and medication prescription cards should be clearly marked that the patient is
self-administering and on which level. Assessment forms should be scanned into RiO
where used and a summary of the outcome noted within progress notes.
When signing for administered medication the chart should be annotated appropriately to
denote self-administration.
All patients must be provided with a medication reminder card (appendix 3) which must be
checked by a second nurse or member of the medicines management team. Any
supporting education should also be provided where appropriate. These cards must be
updated to reflect any changes to prescribed medicines.

Excluded medications

 Controlled drugs
 Injections (unless the patient is / will be self-administering their medications at home
e.g. insulin)
 Once only doses
 Variable regimens may not be appropriate e.g. Loading doses of warfarin, Reducing
courses, Sliding scale insulin or clozapine titration

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 3. Levels of self-administration of medicines

It is possible to enter the self-administration process at any level; patients may also
bypass levels if appropriate.
It is also possible to backtrack where the patient and/or MDT feel appropriate.
Level 1
 The nurse or medicines administration technician (MAT) holds the key/code to the
medication locker or trolley.
 It is the patient’s responsibility to ask the nurse for their medication at
appropriate times.
 If the Nurse/MAT needs to remind the patient to take their medicines, this should be
recorded on the monitoring form
 The nurse/ MAT/MHP will observe that the correct medication is selected and taken.
 Any interventions should be recorded on the monitoring sheet.
 MAT/Nurse/MHP to sign/ chart on JAC.
 Once the patient is deemed competent at stage one progress should be discussed
by the MDT.

Level 2
 Patient is responsible for (a) administering their own medication at appropriate times
(b) securely holding the locker key/code (c) asking nursing staff if they require PRN
medicines
 7 days of medication is stored in the patient’s bedside locker fully labelled with
directions.
 The nurse/MAT supervises the patient in holding the locker key.
 MAT/Nurse to remind patient of the importance of keeping the medication locked
away.
 MAT/Nurse carries out a daily locker security check, and tablet count and signs
paper charts or JAC, annotating with ‘self’ or 7

Level 3
 Patient is responsible for administering their own medication at appropriate
times
 14 days of medication is stored in the patient’s bedside locker/trolley fully
labelled with directions.
 The patient holds the locker key.
 MAT/Nurse carries out a weekly tablet count and security check.

Level 4
 28 days of medication fully labelled with directions is stored in the bedside
locker.
 The patient holds the key.
 MAT/Nurse/MHP carries out a fortnightly tablet count and security check. 6
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 4. Monitoring/Evaluation

All self-administration of medicines (SAM) must be subject to monitoring, supervision and

review by the multidisciplinary team (MDT) including the ward pharmacist. Nurses
/MHPs/MATs should perform security checks and tablet counts according to the self-
administration level the patient is on. This should be documented using the monitoring
sheet (Appendix 4, 5). This should be attached to the drug card or filed in the notes. If a
patient competently and reliably manages their medicines at a given level the MDT should
consider, after reassessment, moving the patient up to the next level appropriate to their
ability.

The level of retained knowledge relating to individual patients’ medicines should regularly
be checked and reinforced as necessary by the registered nurse, MHP or medicines
management team.
If at any time it is considered by a nurse/MHP/MAT that it is unsafe for a patient to
continue on their present level they should be reassessed and either changed to a
suitable level or self-administration stopped. This should be explained to the patient and
documented appropriately.

Patients can also request to go back a stage if they are experiencing difficulties or can
miss a stage if it is considered safe for them to do so. In each case, the appropriate
medical team involved will record the reason for the decision.

Partial self-Administration of Medicines

If the patient wants to retain control of administering a specific medicine but does not want
to self-administer all of their medicines, they may partially self-administer at level 2, 3 or 4.
This is useful for patients who are on time-critical medicines that they manage themselves
at home e.g. insulin, Parkinson’s disease medication. The nurse/MAT must judge that
access to the other medicines in the locker/trolley i.e. those that are not being self-
administered, do not pose a risk.

5. Safety and Accountability

It is the responsibility of the assessing registered nurse/MHP/MAT to ensure that

delegation of medicines administration to the patient is appropriate and the patient is
competent to do so.
Medication must always be stored securely. The patient must be made aware of the
importance of keeping the locker locked and retaining the key on their person (or not
informing other patients of the secure code where lockers have a keypad).
Once a patient is at Levels 3 and 4 it is important to assess how much medication can be
safely supplied.

Medication which the patient may need easy access to such as salbutamol inhalers,
creams and glyceryl trinitrate sprays may be kept by the patient after risk assessment.
Also see 6.
Medication no longer required must be returned to the supplying pharmacy for safe
disposal or disposed of in the medicines waste bin on the ward.
Incidents relating to self-administration should be reported to the medical staff and
pharmacist, recorded in the progress notes and a Trust incident form completed.

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 6. Nicotine Replacement Therapy

Following an individual risk assessment, patients may be given up to 24 hours’ supply of

prn NRT as per Medicines Policy ( SH CP1). It should be labelled with the patient’s name
and may be kept on the patient for self-administration. The total quantity given to the
patient should be documented on each label in addition to the date/time/initials.

7. Compliance Aids

Compliance aids are often inappropriately used for patients. They are often used when a
simpler tool e.g. Reminder cards, would support concordance. All concordance issues
should be discussed with the pharmacist or MAT. Staff are also referred to the Trust
Procedure on Filling and Checking a Compliance Aid” SH CP 170. Medicines in a
compliance aid e.g.; Nomad®, may only be used for self-administration after they have
been assessed for appropriateness by a pharmacist or pharmacy technician.

8. Monitoring Compliance

Monitoring of this guideline will be undertaken as part of Medicines Control, Administration

and Prescribing Policy audit.

9. Related Policies

SH CP 1 Medicines Policy
SH CP 170 Procedure on Filing and Checking a Compliance Aid

10. References

Audit Commission. A spoonful of sugar – medicines management in NHS hospitals.

London: Audit Commission; 2001

Department of Health, National Service Framework for Older People. The Stationary
Office; 2001

Altman I et al: Self-administration of Medicines in Brighton; Hospital Pharmacist

2002;9:305-307

Policy for Self-administration of Drugs, Renal Unit, Derriford Hospital

Care Quality Commission: Essential Standards of Quality and Safety, March 2010:

Outcome 9: Management of Medicines:

http://www.cqc.org.uk/sites/default/files/media/documents/essential_standards_of_quality
_and_safety_march_2010_final_0.pdf

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 Appendix 1 Self administration assessment form

Patient name: Assessed by:

Ward: Date:
NHS number:

Will the patient assume responsibility for taking their medication at Y/N
home? If yes-
(If a package of care is planned will carers be responsible for administering continue
medication?)

Y/N
Is the patient expected to remain on the unit for at least 7 days?
If yes-
continue
Has the patient understand the self-administration of medicines Y/N
process and do they want to take part? If yes-
continue
Is the patient confused or has an unstable mental state? Y/N
If no-
continue
Does the patient have a history of drug and/or alcohol abuse? Y/N
(If yes – the patient may only be suitable for stage 1) Restrictions, if
any, to be stated
below

Does the patient have a history of overdose, accidental or intentional? Y/N

(If yes – the patient may only be suitable for stage 1)
Restrictions, if
any, to be stated
below

Does the patient use a compliance aid? Y/N

May not be suitable for this scheme

Can the patient open child resistant closures? Y/N
What steps have been agreed to overcome this problem?
Does the patient require any other adjustments to support self- Y/N
administration of medicines e.g. tablet splitter/crusher, eye drop aid,
bottle gripper, Haleraid. More example as at:
https://www.cpsc.org.uk/application/files/4415/0937/2145/MDS_Doc.pdf
Is the patient aware of any special instructions associated with their Y/N
medication?
What steps have been agreed to overcome this problem?
Can the patient read standard medication labels in English? Y/N

Notes:

Recommendation:

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 Appendix 2: Self-Administration consent form

PATIENT AGREEMENT CONSENT FORM

 I have discussed the self-administration procedure and wish to be assessed

under the requirements of the self-administration of medicines procedure.

 I understand that once I reach level three I assume total responsibility for my
medication.

 I am responsible for my locker key/code, the key must be kept on my person.

 My medication is for my use only.

 If anyone takes or tries to take my medication I must let a member of ward

staff know.

 If I require further supplies of medication I will let ward staff know.

 Expired medication or medication I am no longer prescribed will be removed

and disposed of.

 I may withdraw from the scheme at any time.

 I understand that I may be removed from the scheme if medical, pharmacy or

nursing staff deem it necessary. I will be given an explanation as to why.

Signature of Patient …………………………………………………………………

Name Printed: …………………………………..…………. NHS No. ……….……….

Signature of Staff ………………………………………………………….

Name (Printed) ……………………………………………………………………………

Date …………………………………………………………….

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 Appendix 3 – Medication Reminder Card

This chart is intended to help you remember

when to take your medicines.
Please show it to any healthcare professional PATIENT MEDICATION REMINDER CHART
(i.e. doctor, nurse, pharmacist) who prescribes or
gives advice about your medicines. ALWAYS bring this reminder chart and your
If anyone changes your medicines, please ask
them to change the reminder chart. NAME:
Ward: Hospital:
IMPORTANT POINTS ABOUT YOUR MEDICINES:
1. Medicines are an important part of your treatment Written by: Date:
and each one has been individually prescribed for Checked by: Date:
you.
2. It is important that you take your medicines as
instructed on the label so that your response to
treatment can be monitored. current medicines with you when coming
3. Do not stop or change how you use your into hospital or clinic.
medicine without telling your doctor first. If you
PLEASE NOTE:
experience any side effects inform your
doctor/pharmacist as soon as possible. This information is correct at the time it is written. This is
4. Always store medicines safely & keep out of not a repeat prescription.
reach and sight of children. Please contact the surgery to ensure your medicines
5. Take unwanted/out of date medicines to your have been updated and to obtain further medicines.
pharmacy. Medicines Management Team, SHFT Adapted from Countess of Chester
Hospital NHS Foundation Trust.
6. Remember your medicines are for your use only.
Do not share your medicines with other people.
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 Date stopped
Morning Midday Teatime Bedtime
Whats the Additional advice
Date started

Medication Name and strength medication

for?

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 Appendix 4: Tablet count sample record form

Tablet
Medication Date Starting count Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
count
Expected
Actual
Expected
Actual
Expected
Actual
Expected
Actual
Expected
Actual
Expected
Actual
Any discrepancies?

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 Appendix 5 Progress report

Self administration of medicines monitoring

Stage ……. Progress Report

PATIENT’S NAME ………………………………………NHS NUMBER………………….

To be completed by a trained nurse/MHP/MAT on a daily/weekly/fortnightly basis.

Any identified problems or concerns must be documented within the nursing notes

Date Any problems identified – Signature

Yes /no.
If yes please specify.

Patient suitable to move onto stage …….

Signature…………………………………….……………………..(date)

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