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Self-administration of Medication for Adults SOP

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Title

SELF-ADMINISTRATION OF MEDICATION FOR ADULTS STANDARD OPERATING PROCEDURE

Author

Author’s job title Medicines Management Technician Lead Pharmacist Community Services

Directorate Planned Care

Department Team/Specialty Pharmacy Medicines Management Eastern

Version Date

Issued Status Comment / Changes / Approval

3.0 Oct 2013 FINAL Final Standard Operating Procedure published on BOB

3.1 August 2015

Draft Document review March 2016

4.0 Feb 2016

Final Draft

For consultation and Drugs and Therapeutics Committee on March 17th 2016 for ratifying.

4.1 May 2017

Revision Medicine Governance group requested statement to be added to Appendix 3 that patient understands they need to keep pin codes confidential.

Main Contact Lead Pharmacist Northern Devon Healthcare Trust Unit 1, Exeter International Office Park Clyst Honiton Exeter EX5 2HL

Tel: Direct Dial – 01392 356963

Lead Director Chief Pharmacist

Document Class Standard Operating Procedure

Target Audience Nursing Staff in Community Hospitals -Wards/Units

Distribution List Hospital Matrons/Ward Managers Day care Managers Pharmacy Teams

Distribution Method Trust’s internal website

Superseded Documents Self-Administration of Medication FINAL SOP v3.0 28Oct13[1]

Issue Date May 2017

Review Date May 2020

Review Cycle Three years



Consulted with the following stakeholders: (list all)

Hospital Matrons Day Care Manager Safeguarding Adult Lead Diabetes Specialist Nurses

Contact responsible for implementation and monitoring compliance: Lead Pharmacist Community Services Deputy Director of Nursing

Education/ training will be provided by: Pharmacy and Medicines Management Team

Approval and Review Process

Drugs and Therapeutic Committee

Local Archive Reference G:\MEDICINES MANAGEMENT\Policies\Medicines Management Policies\New Northern Devon Policies And Sops\SOP Self-administration\Documents for Version 3\ Self-administration of Medication for Adults FINAL SOP v3.0 28Oct13[1] Local Path G:\MEDICINES MANAGEMENT\Policies\Medicines Management Policies\New Northern Devon Policies And Sops\SOP Self-administration\ Filename G:\MEDICINES MANAGEMENT\Policies\Medicines Management Policies\New Northern Devon Policies and SOPs\SOP Self Administration\Final Draft Feb 2016\Self-administration of Medication Final Draft v3.2.docxS

Policy categories for Trust’s internal website (Bob) Pharmacy

Tags for Trust’s internal website (Bob) Self-administration, medicines management, medicines, patient’s own drugs.



CONTENTS

Document Control........................................................................................................................ 1

1. Background .......................................................................................................................... 4

2. Purpose ................................................................................................................................ 4

3. Scope ................................................................................................................................... 4

4. Location ............................................................................................................................... 5

5. Equipment ............................................................................................................................ 5

6. Procedure ............................................................................................................................. 5

7. References.......................................................................................................................... 11

8. Associated Documentation ................................................................................................. 11

9. Appendices ......................................................................................................................... 12

Appendix 1: Patient Information ................................................................................................ 13

Appendix 2: Assessment checklist .............................................................................................. 14

Appendix 3: Accepting responsibility statement.......................................................................... 17

Appendix 4: Trial Assessment form ............................................................................................. 18



1. Background

1.1. Healthcare staff have a role and duty of care to promote the safe and appropriate use of medication. This will include support to enable patients to self-administer their own medication where appropriate.

1.2. Registered staff must administer the medication to patients who cannot self-administer medication.

1.3. Self-administration of medication must be supported for adults in all in-patient and day care settings, where the required medication and equipment is available and where the patient has been assessed as having capacity (physical/mental) to undertake self-administration of medication.

MCA FORM/SAFEGUARDING ADULTS ASSESSMENT.

http://ndht.ndevon.swest.nhs.uk/wp/wp-content/uploads/2011/07/Combined_Consent_and_-capacity-assessment_for_admission_to_caseload_or_intervention_-V4-241214-amends.pdf

2. Purpose

2.1. This Standard Operating Procedure (SOP)

Informs healthcare staff, employed by Northern Devon Healthcare NHS Trust in an in-patient/day care setting about the assessment process and subsequent required action(s)to support patients to self-medicate.

It supports patients who are willing to be assessed and have the capacity (physical/mental) to self-medicate.

3. Scope

3.1. This Standard Operating Procedure (SOP) relates to the following staff groups who may be involved in the self-administration assessment and delivery of care:

Registered nurses

Support workers

Medical staff

Pharmacy staff







4. Location

This Standard Operating Procedure can be implemented in all in-patient settings and day care areas where competent staff are available to undertake this role. Staff undertaking this procedure must be able to demonstrate continued competence as per the organisations policy on assessing and maintaining competence.

5. Equipment

Self-administration of Medication for Adults documentation, Appendix 1-5.

Fixed and secure cupboard/locker located near the patient.

Keys/codes for the patient’s cupboard/locker.

Forms and guidance information.

Named patient medication/Patient’s own medication.

6. Procedure

6.1 Self- administration of Medication for Adults

Assessment

6.1.1 All adult patients should be considered for their suitability for self-administration of medication. This should take place at the patient’s initial assessment and at intervals during their episode of care, depending on their underlying condition. However, any need for extra supervision and reinforcement of education must be documented in the patient’s clinical records/care plan by nursing staff. (NMC –standards for medicines management pg.87: annexe 4). Patients with a history of drug/alcohol abuse are not excluded from self-administration of medication. However, addictive replacement therapy cannot be included, e.g. methadone.

6.1.2 There are three levels identified for the self-administration of medication for adults.

The level considered appropriate must be documented in the patient’s clinical records/care plan.

LEVEL 1

The registrant is responsible for the safe storage of the medicinal products and the supervision of the administration process ensuring the patients 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 or locker. The patient will then self-administer the medication under the supervision of the registrant.



LEVEL 3 The patient accepts full responsibility for the storage and administration of the medicinal products.

(Nursing and Midwifery Council – Standards for Medicines Management 2010)

6.1.3 All patients who are independently self-administering on admission can be assessed on arrival. If there are suitable ‘Patient’s Own Medication’ available, the patient can be placed on level 2 under – Continued Independent Self-administration for a period of 24 hours using a medicines reminder chart or the Prescription Administration Record (PMAR). The patient must be observed taking their medication by a registrant during this period and the PMAR signed by the registrant. If, the patient is compliant they can administer independently at level 2 or 3. All the stages must be documented in the patient’s care plan.

6.1.4 The patient’s level of self-administration must be reassessed regularly to maintain

patient safety, especially if there are any changes to clinical circumstances or the patient receives certain procedures. E.g. the patient has been anaesthetised or given high doses of controlled analgesia within the last 24 hours must be placed at level 1.

6.1.5 Patients who are considered for the self-administration of medication scheme

should be supplied with Appendix 1 ‘Patient Information’ leaflet and understand the contents. A registered professional of the multi-disciplinary team will then assess the patient using the appropriate form, Appendix 2.

Responsibility

6.1.6 The patient must be mentally and physically able to self-administer medication; this includes using any equipment they may already be using within their home environment. Mental capacity must be assessed using the approved format and documentation. Staff must remember that mental capacity may vary during a care episode and therefore needs to be reviewed depending on the individual’s requirements.

6.1.7 The patient must be willing to self-administer medication and sign the approved

consent form (Appendix 3) before taking responsibility for self-administration of medication. The responsible person initiating the self-administration of medication process must sign and date the front of the Medicines (PMAR) chart and countersign the consent form. Patients have the option to include all of their medications or only specific medicines e.g. Insulin. This includes Drugs of Diversion and Controlled Drugs which must be recorded separately in the relevant Patient’s Own Drugs registers and then the total amount is signed out to the patient. Only ward stock is signed out at one dose at a time to individual patients. Receipt/Consent form must be completed with CDs and DODs (refer to the relevant SOPs).

6.1.8 Patients who attend a day clinic/surgery must be assessed and sign the ‘Accepting Responsibility Statement’ Appendix 3. If suitable the patient is able to be responsible for the security of their medicines at level 2 or 3. The patient will be observed on their first visit to the day clinic/surgery by a registrant at Level 2. This equates to the 24 hour observation period carried out in a ward setting. If successful, on the patient’s next visit they will be able to self-administer their medicines at Level 2 or 3.



Review 6.1.9 The patient’s level of self-administration must be reassessed regularly to maintain

patient safety, especially if there are any clinical changes or the patient receives certain procedures. E.g. the patient has been anaesthetised or given high doses of strong analgesia within the last 24 hours should be placed at level 1.

6.1.10 All reviews and changes to the Levels must be documented in the clinical

records/care plan.

6.1.11 If there are concerns or difficulties regarding compliance, self-administration of medication must be stopped and the medication administered by registered professional staff. The multi-disciplinary team and prescriber/general practitioner must be informed.

6.1.12 The patient can withdraw from the self-administration of medication process at any time and then the responsibility for the administration of medication will be with the unit/ward staff.

Self-administration of Medication for Adults in an In-patient Setting

6.1.13 The agreed ward care plan should include the medications which are being self-administered and those that are required to be administered by registered staff.

6.1.14 All Patient’s Own Drugs (PODs) and ward stock of Drugs of Diversion and Controlled Drugs must be recorded in the separate registers as stated in the CD and DOD SOPs.

6.1.15 The care plan should outline the review process including the dates for review and checks for medication compliance.

6.1.16 If the patient was non-compliant in taking their medication before admission or has had a notable change in their abilities, use the trial (amber)route on the flowchart (App 5) to assess their ability to self-administer. This is a rehabilitation trial period used before discharge from the hospital, facilitated by a medicines reminder chart.

6.1.17 Adherence with the medication prescribed and self-administered should be assessed using the Self-administration of Medication for Adults Trial Assessment Form, (Appendix 4). This must be filled out by a registered professional and checked by a second registered professional.

6.1.18 To promote medicines compliance in levels 2 and 3 the assessment should initially be on a daily basis until it has been established that appropriate self-administration of medication has been achieved. Staff will record when the patient has self-administered their medication after each dose by writing ‘self’ on the administration (PMAR) chart and signing their initials. (Level 3 Self-administration of Medication). The registered professional remains responsible for signing the prescription chart after every dose for all the medications. This is a continual assessment of the patient’s adherence and safety.



6.1.19 Information must be given to the patient on their current medication using a medication reminder chart which must be signed by two registered professionals. Appropriate Patient Information Leaflets (PIL) must also be supplied as a package insert with each medication.

6.1.20 ‘As required’ medication may be included in the Self-administration of Medication for Adults Scheme after appropriate assessment. However, the patient MUST inform staff when a dose has been taken and it must be documented/signed for on the PMAR by the registered professional.

6.1.21 Injectable medicines are excluded from self-administration of medication with the exception of insulin, following an assessment and technique appraisal. All other injectable medications are to be discussed with the pharmacy team if inclusion is required. This must be documented in the patient’s notes.

6.1.22 Insulin is not only self-administered it is also self-managed. This is where the patient tests their blood glucose levels, records the result and adjusts the insulin levels to be administered accordingly then record the injection site. Level 3 must not be considered until the patient has administered their medication correctly for at least 24 hours under observation.

6.1.23 The insulin must be labelled specifically for the patient and kept at room temperature during use then discarded after 28 days.

6.1.24 If, the patient’s condition alters so they can no longer self-administer their agreed medication it is essential that a review process is undertaken at an agreed time to review the initial decision.

6.2 Medication

6.2.1 Medication for use on the Self-administration of Medication for Adults Scheme can be obtained by using:

- Patients Own Drugs (PODs) - Medication supplied on an FP10 or FP10HNC prescription - Medication supplied as a ‘To Take Out’ (TTO)

6.2.2 All Patients Own Drugs (PODs) must be assessed as fit for purpose according to the

Patients Own Drugs for Inpatient Setting SOP.

6.2.3 The medication and packaging must be intact, in good condition and the label must clearly state the following:

Patient's name

Medicine’s name

Strength

Formulation

Dose



Administration instructions

Applicable Warnings

Date of dispensing (within last 6 months or last 28 days for controlled drugs) Refer to Standard Operating Procedure (SOP) ‘Use of patients’ own drugs for in-patient and day care setting’ for further guidance.

6.2.4 The Patient’s Own Drugs (POD) will be recorded as being available on the admission checklist, medicines reconciliation form, care plan and ‘Patient’s Own Controlled Drugs and Drugs of Diversion Receipt/Consent Form’ where appropriate.

6.2.5 The name of the medication and quantity supplied to support the trial period will

also need to be entered on the Self-administration of Medication for Adults Trial Assessment Form, Appendix 4 for an in-patient setting.

6.2.6 All medication, for in-patients undertaking self-administration of medication, must

be prescribed on the Prescription and Medication Administration Record (PMAR) chart and be individually dispensed and specifically named for the patient with instructions.

Storage and Security

6.2.7 In day care settings a patient’s medication is their property and remains in their possession. This includes being responsible for the safe storage of their medication e.g. kept on their person or in a secure bag or a locker if available. Follow the flowchart for successful self-administration of medication patients using the ’Day Units/ Clinics’ route.

6.2.8 In inpatient settings the medication must be kept in a lockable cabinet/cupboard on the unit/ward which is designated for this purpose in an in-patient setting.

6.2.9 Keys/codes to individual lockable cupboards will be held by patients as identified in levels 1-3 section 6.1.2.

6.2.10 A master key/code will be kept by the registered professional in charge of the ward or unit.

6.2.11 If any individual key/code are lost the medications must be:

Secured as appropriate on the unit/ward.

All attempts will be made to ensure that the patients receive their medication in a timely manner.

In addition: The line manager/senior manager on duty/call must be notified.

The lock/s may need to be changed.

The incident will be reported in accordance with the Northern Devon Healthcare Trust Incident reporting policy.

6.2.12 If there are special storage requirements for a certain medication the staff will need to consider whether this preparation can be kept with the patient or stored separately with consideration to patient access. E.g. in the refrigerator for insulin, creams, eye drops.



6.2.13 Controlled Drugs and Drugs of Diversion may be kept in the patient’s fixed, locked cabinet for the purpose of the Self-administration of Medication for Adults Scheme. The medication must be managed in accordance with the Drugs of Diversion and Controlled Drugs SOPs.

6.2.14 Unwanted medication will be disposed of according to the Trust’s Waste Management policy, the Standard Operating Procedures (SOP) Management of Pharmaceutical Waste, Controlled Drugs and the Drugs of Diversion. In addition, consent must be obtained from the patient prior to the destruction of all Patients’ Own Drugs (PODs) including Controlled Drugs (CD) and Drugs of Diversion (DOD). Complete a Patient’s Own Controlled Drugs and Drugs of Diversion Receipt/Consent Form found in the CD and DOD SOP.

Equipment

6.2.15 Compliance aids may be used for self-administration of medication for adults. However, nursing staff should not undertake the refilling of these aids or make any adjustments to them.

6.2.16 If a compliance aid/blister pack is a new system to the patient, give them clear guidance. E.g. on how to take the right medication by choosing the correct day of the week and time of day from the compliance aid. Explain the process of how to renew the compliance aid. E.g. where to order it from and when. If appropriate, and with the patient’s consent, include a family member when giving this guidance to facilitate support in the home.

6.2.17 All of the patient’s medication must be returned to them on discharge/transfer in order to facilitate the continuation of self-administration of medication after their discharge. Document the movement of medication in the allocated registers and patient’s notes. If the medicines are no longer required, written consent should be obtained from the patient tol allow the staff to destroy the medication on the patient’s behalf, as documented in SOP (Use of Patients Own Drugs (PODs) for in-patient and day care settings). Use the ‘Patient’s Own Controlled Drugs and Drugs of Diversion Receipt/Consent’ form in the CD SOP.

6.2.18 Where equipment is used e.g. a nebuliser, staff need to assess if the unit’s or patient’s own equipment is to be used. If the latter, arrangements need to be made with estates to check any electrical equipment before it is used on the ward.

6.2.19 The cleaning of any equipment used will be in accordance with the infection control guidelines. The patient will be aware of when to clean the equipment and the required products to be used.

6.3 Adverse Drug Reaction/Incidents

6.3.1 In the event of an adverse drug reaction, immediate care will need to be undertaken to minimise harm to the patient, this event must then be recorded in the patient’s notes. Also, the medication which prompted the adverse reaction and the type of reaction. E.g. rash, must be entered into the notes. The nurse/manager in charge and the prescriber must be informed, as soon as possible, after the patient’s needs have been addressed.



6.3.2 The patient’s General Practitioner (GP) must be informed if this is not the prescriber.

6.3.3 Adverse Drug Reactions (ADRs) should be reported using the Yellow card and be sent to the Medicines and Healthcare products Regulatory Agency (MHRA) – details are contained in the British National Formulary. (BNF). This can be undertaken by the unit staff or the patient if this is appropriate. In addition, the report can be completed on line: www.yellowcard.gov.uk

6.3.4 Any incidents must be recorded in the patient’s records indicating the actions taken. The unit’s staff have a duty to report any undue incidents while the patient is self-administering medication. This will follow the NHS Northern Devon Healthcare Trust incident management policy (Complete a Datix report).

7. References

Mental Capacity Act 2005

NICE Guidance: CG 76 Medicines Adherence January 2009

Nursing and Midwifery Council; Standards for Medicines Management Aug 2007 reprinted August 2010

Nursing and Midwifery Council. The Code. Standards of Conduct, Performance and Ethics for Nurses and Midwives 2008

Trust’s Waste Management Policy

Diabetes UK – Self-management of diabetes in hospital. Joint British Diabetes Societies for Inpatient Care Group. March 2012

8. Associated Documentation

8.1. Northern Devon Healthcare NHS Trust Policies for :

Northern Devon Healthcare NHS Trust Consent policy

Northern Devon Healthcare NHS Trust Medicines Policy and Associated Standard Operating Procedures including:

- Controlled Drugs

Controlled Drugs (CDs) Ordering, Receipt & Stock Management Standard Operating Procedure | Policies

Patient’s Own Drugs

http://www.yellowcard.gov.uk/

http://ndht.ndevon.swest.nhs.uk/policies/?p=11467




Patients’ Own Drugs (PODs) for inpatient setting – Standard Operating Procedure | Policies

Northern Devon Healthcare NHS Trust Incident Management Policy

Northern Devon Healthcare NHS Trust Injectable Medicines Policy

Northern Devon Healthcare NHS Trust Waste Management Policy

Safeguarding Adults Policy

9. Appendices

Appendix 1: Patient Information on Self-administration of Medicines Scheme

Appendix 2: Assessment checklist for Self-administration of Medication for Adults Scheme

Appendix 3: Self-administration Scheme Accepting Responsibility Statement

Appendix 4: Self-administration of Medication Trial Assessment form

Appendix 5: Self-administration of Medicines Flowchart





Appendix 1: Patient Information

PATIENT INFORMATION

ON

SELF-ADMINISTRATION OF MEDICINES FOR ADULTS SCHEME

WHAT IS SELF-ADMINISTRATION OF MEDICINES?

The Self-administration of Medicines for Adults Scheme encourages patients to remain or become independent, in taking responsibility for their own medication on the ward and thereafter at home. You will be given a supply of medicines or you may use your own if you have brought a supply with you. The medicines will be kept in a locked bedside locker and you will be given the key. You will then take the medication correctly yourself whilst you are on the ward. The scheme is designed for those patients who are normally, or will be, responsible for their own medicines whilst in their own home.

DO I HAVE TO JOIN THE SCHEME?

It is not compulsory, but it would be preferable for you to join the scheme so that it gives you a chance to rectify any problems regarding medication before you are discharged from hospital.

WHAT ADVANTAGES DOES THE SCHEME HAVE?

● An opportunity to improve your knowledge about your medication and to get used to any recent changes that the doctor has made.

● The flexibility to take your medicines at a time that suits you and your condition best.

● More independence and control during your stay on the ward.

WHAT HAPPENS NEXT?

● A member of Nursing/Pharmacy staff will give you a more detailed explanation about self-medication, what it involves and whether self-medication is suitable for you.

● Information is given to you about each medicine that you are taking, including doses and possible side effects.

● You will be given a medicines reminder chart to help you take the medicines at the right time of day.

You must sign the Self-administration of Medication for Adults Scheme Accepting Responsibility Statement Appendix 3.

IF YOU HAVE ANY QUESTIONS, PLEASE ASK ONE OF THE WARD STAFF.

Do you wish to join the Self-administration of Medicines for Adults Scheme? YES / NO

Date:



Appendix 2: Assessment checklist

ASSESSMENT CHECKLIST FOR SELF-ADMINISTRATION OF MEDICATION FOR ADULTS SCHEME

Name:

Address:

(or insert label)

NHS / Unique Identification No:

Date of Birth:

Allergies:

Complex care team/ward:

Hospital:

Admission / Referral Date

A. THE PATIENT

YES NO N/A

1. Does the patient administer their own medication at home?

2. Does the patient understand how and when to take their medication?

3. Can the patient access their medicines, the locker and manipulate the locker key?

4. Does the patient understand how to use any equipment used for the administration of their medication? i.e. (Nebuliser/Insulin)

5. After receiving an explanation of the scheme, does the patient want to take part in the scheme and understand the requirements for inclusion into the scheme?

Self-administration of medication

Storage of medication

Reporting problems

6. Has the patient signed the ‘Accepting Responsibility Statement’? (Appendix 3)

If the answer is NO to any of the above, further investigation may be required into the suitability of the individual to enter the self-administration scheme.

RESULT OF ASSESSMENT FOR THE LEVEL OF SELF-ADMINISTRATION

LEVEL 1 The registrant is responsible for the safe storage of the medicinal products and the supervision of the administration process ensuring the patients 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 or locker and access the medications. The patient will then self-administer the medication under the supervision of the registrant.

LEVEL 3 The patient accepts full responsibility for the storage and administration of the medicinal products.



YES NO N/A

Circle the level of self-administration following initial assessment. Indicate the agreed medicinal products to be self-administered:

Level 1 2 3

The patient will self-administer the following: (please tick Yes/No or N/A):

All of their own medicines

Insulin

Inhalers

Creams, eye drops, tablets, pain relief

Nutritional drinks

Drugs of Diversion

Controlled Drugs

Circle the level of self-administration following re assessment :

Level 1 2 3

B. THE MEDICATION

Patients Own Drugs (PODs) and Medicines Reconciliation

In-patients

The Patient’s Own Drugs (PODs) must be available to use and be recorded on the Prescription and Medication Administration Record (PMAR) to complete the Medicines Reconciliation process.

Day Care Patients

A list of the patient’s current medication from the General Practitioner must be available for the Medicines Reconciliation, as well as information on the PODs. This information may be gathered at the same time as the FACE (Functional Analysis of Care Environment) assessment in the patient’s home for Day Care patients and used on the Day Unit as the ‘Patient’s Own Medication’ for the Medicines Reconciliation process. The medicines are recorded on the Medicines Reminder Chart, Appendix 4.

YES NO N/A

1. Does the label clearly state:

Patient’s name?

Medication name, form and strength?

Dosage instructions?

Any other administration instructions?

Name of Dispensing Pharmacy?



Date of Dispensing?

2. Are the containers intact?

3. Do the labels and contents match?

4. Have the medicines been stored appropriately prior to admission e.g. fridge items

5. In-patients (ward)

Are locked cupboards with a key available for each patient?

Day Care Units:

Can the patients take responsibility for the security of their own medication?

If, the answer is NO to any of the above questions the patient’s medication must be administered by registered professionals to the patient from the completed Prescription ad Medication Administration Record.

C. THE OUTCOME

(i) APPROVAL

(Name)………………………………………………………….. has been assessed and has consented to undertake

self-administration of medication for adults of Level 1, 2, 3 with trial/without trial period (delete

as required).

Assessed by (print name)............................…………………………… Date/Time: ……………………………………

Role: ..........................................................................................

The Self-administration of Medication Trial Assessment Form, Appendix 5, must only be completed for in-patients taking part in a self-administration of medication trial.

Self –administration of medicines written in the patient’s care plan YES/NO (if no, add to care plan)

(ii) REFERRAL

Refer any patients with concerns raised during this assessment to a healthcare professional for investigation (Pharmacist / Pharmacy Technician). Record outcome.

Referred to:………………………………………………..………………………… Date/Time : …………………………………..

Referred by: ……………………..…………………….…….. Role: ............................................................



Appendix 3: Accepting responsibility statement

SELF-ADMINISTRATION OF MEDICATION FOR ADULTS SCHEME

ACCEPTING RESPONSIBILITY STATEMENT

I, fully accept the responsibility for any medicines in my possession and consent to the use of my own medicines.

I, undertake to keep them secure or place them in a locked cabinet where one is provided.

I, understand I need to keep the pin number to my locker confidential.

I, understand that these medicines are for my personal use only. I will not give the medicines to any third party and will inform a member of staff if requested to do so.

I, am willing for any unsuitable medication to be removed and destroyed if necessary.

I, understand I may withdraw from the scheme at any time by informing the nurse.

In-patient / Day care patient (delete as required)

NAME (Block Capitals): ……………………………………………………………………..……………………………………………

Signed: ……………………………………………………………………… Date/Time……………………………..…………

Witnessed by:

NAME (Block Capitals): ……………………………………………………………………….…………………………………………

Signed: ……………………………………………………………………… Date/Time……………………………..…………

Role: ……………………………………………………………… Department: ………………………………………………………

Hospital: …..……………………………………………………………………………………………………………..…………………….

Self-administration of Medication for Adults SOP Northern Devon Healthcare NHS Trust Incorporating Community Services in Exeter, East and Mid Devon


Appendix 4: Trial Assessment form

FOR USE BY REGISTERD PRACTITIONERS SELF-ADMINISTRATION OF MEDICATION FOR ADULTS - TRIAL ASSESSMENT FORM

Name:

(or insert label)

Complex care team / Ward:

Date of birth:

NHS/Unique identification no:

Admission / Referral Date:

DRUG DOSE FREQUENCY QUANTITIY SUPPLIED

DATE:

TIME:

………..

………..

………..

………..

…………

…………

…………

………….

…………

………….

……….

……….

ACTUAL AMOUNT

PREDICTED AMOUNT

ACTUAL AMOUNT

PREDICTED AMOUNT

ACTUAL AMOUNT

PREDICTED AMOUNT

ACTUAL AMOUNT

PREDICTED AMOUNT

Guidance for trial assessment: Initially on a daily basis and review according to the outcome. Successful trials are assessed at least once a week. Document the set dates for on- going reviews. If, the patient’s condition deteriorates reassess using Appendix 2.

Prepared by: NAME:.…………….……………… SIGNATURE:.…………………….. ROLE…………………………..……… DATE/TIME: …………..……/…….………

Checked by: NAME:......................................... SIGNATURE:................................ ROLE:............................................... DATE/TIME:......................./....................

Self-administration of Medication for Adults SOP Northern Devon Healthcare NHS Trust Incorporating Community Services in Exeter, East and Mid Devon

Eastern Medicines Management

Self-administration of Medication Final v4.1 of 19

Appendix 5: Self Administration of Medicines for Adults Flowchart

SELF–ADMINISTRATION OF MEDICINES FOR ADULTS FLOWCHART

PATIENT ADMISSION

& ASSESSMENT

NB: A patient’s level of capability may

fluctuate, implement regular reviews

Patient Information and Explanation Leaflet

Appendix 1

Assessment Checklist for Self-administration

Appendix 2

Assess patient – Level 1, 2 or 3

RECORD ASSESSMENT

Annotate front page of PMAR

Record level of self-administration 1,2 or 3

Record in care plan ,clinical notes and PMAR

SELF-ADMINISTRATION

& RESPOSIBILITY

Accepting Responsibility Statement

Appendix 3

Patient to sign statement

24 HOUR OBSERVATION PERIOD BY A

REGISTRANT (level 2)

Record self-administration on PMAR by writing

“self” and initial the entry

Successful – continue self-administration to Level 3

Unsuccessful –Stop/Review or trial

TRIAL FOR REHABILITATION BEFORE

DISCHARGE

Appendix 4 and MRC

Daily count required until next planned review date

Successful – continue self-administration

Unsuccessful - STOP

KEY Level 1: Code / Locker key with staff & staff to administer. Level 2: Code / Locker key with staff & patient to administer. Level 3: Code/ Locker key with patient.

POD: Patient’s own drugs PMAR: prescription medication administration record (inpatient drug chart) TTO: To take out (discharge / FP10 prescription) MRC: Medicines Reminder Chart

MEDICINES ASSESSED FOR

SUITABILITY AND/OR LABELLED

SUPPLY OBTAINED

Assess Patient’s Own Medicines (PODs): Blister

pack, Nebuliser, Inhaler, cream, eye drops etc.

Insulin

Appendix 2

SAFE AND SECURE Make sure each patient has access to a lockable

bedside cabinet for their medication.

Successful patients in day units/clinics take

responsibility/security of their medicines

PLANNED REVIEW Continue Level 2 or 3