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GUIDELINES FOR
PATIENT SELF-ADMINISTRATION
OF MEDICATION (SAM)
Title:
Guideline
Reference:
CGP20
CQC Outcome:
Version:
Version 3
Approved by:
Ratified by:
Date ratified:
21/10/2014
Name of originator/author:
Review Frequency:
3 years
Review date:
October 2017
Target audience:
www.peninsulacommunityhealth.co.uk
Contents
1
2
3
4
5
6
8
9
10
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
6.4 Patient Consent ............................................................................................9
6.5 Patient Education .........................................................................................9
6. 6 Prescribing, Storage and Dispensing Medications for SAM.........................9
6.7 Administration and Documentation.............................................................13
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 ..................................................................................15
7.3 Dissemination .............................................................................................15
7.4 Storing the Procedural Document...............................................................16
Process for Monitoring Effective Implementation............................................................. 16
Associated Documentation .............................................................................................. 16
References ...................................................................................................................... 16
Appendices
Appendix 1 Self Administration Assessment and Consent Form and variance form.19
Appendix 2 Self Administration Levels ..21
Appendix 3 SAM Quick Reference Guide .21
Appendix 4 SAM Flow Chart 22
Appendix 5 Variance Form23
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 Patients 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 Medicines38
Appendix 15 NMC Standard 10 Self-Administration Children and Young People 40
Appendix 16 NMC Standard 16 - Aids to Support Compliance.. 41
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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.
Type of Change
Date
Description of change
Creation
2010
Amendment
2011
Review
June 2014
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1 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.
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 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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5 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.
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6.1 Aims
Self-Administration of Medications has two broad aims:
Exclusion criteria
Caution criteria
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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The NMC provides guidance on the Levels at which a patient can self-medicate (see
Table 1 below) (NMC 2008).
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Level 2
Level 3
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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).
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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
Patients 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).
In addition the NMC has provided guidance on the use of patients own medicinal
products (see Appendix 13) (NMC 2008, Standard 5).
The assessment of the suitability of the Patients Own Drugs must be documented on
the Self Administration Assessment and Consent Form (Appendix 1).
6.6.2 Checking Patients Own Medications
Patients 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.
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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 patients own medications, medical/pharmacy staff need to be satisfied that the
details and drugs match up with the prescription chart.
An entry should be made in the patients 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.
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
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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.
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
self-medicate. A supply of blank labels can be obtained from pharmacy. The
label should meet the labelling requirements (see 6.6.1)
Determine if the patient can commence Level 3 Self Administration, or if they
require induction at Level 1 and/or Level 2 prior to Level 3.
Level 3
Patient will need the following documentation
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.
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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.
Audit results will be reported to the Quality and Patient Safety Committee.
9 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
10 References
Policy for the Development and management of procedural documents.
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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
Name:
Consultant:
D.O.B:
Ward:
(Please circle)
CR No:
YES
NO
Signed :
Date:
PATIENT ASSESSMENT Based on the questions below, please assess and indicate whether you consider
the patient fully competent to self-administer their medicines (see also overleaf and 6.2 Guidelines for SelfAdministration of Medicines Policy).
Patients requiring additional support initially, may commence at Level 1 or Level 2 self-administration (refer to
Assessment section 6 in Guidelines for Self-Administration of Medicines Policy).
Only record again if competence changes
Date
Questions (answer Y/N)
1. Does the patient usually take
responsibility
for
their
own
medications?
2. Has SAM been explained to the
patient and the patient information
leaflet been given?
3. Has the patient read and
understood the leaflet explaining
self-medication?
4. Has
patient
consent
been
obtained?
5. Is the patient competent to make
decisions?
6. Can he/she read the labels and
open the containers?
7. Does he/she understand the
dosage, timing and any special
instructions?
8. Does the patient understand the
purpose of his/her medications?
YES for each of the above indicates the patient is assessed as competent to self-medicate unsupervised,
assessing medication from the bedside cabinet independently using key (Level 3).
Name of nurse completing assessment
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Signature
Date
Insulin
Inhalers
Yes/No
Yes/No
Doctor signature
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Patient selection (see section 6.2 Guidelines for Self-Administration of Medicines Policy )
Inclusion Criteria
Exclusion criteria
Cautions
Patients whom appropriate
Patients at imminent risk of
History of alcohol and
members of the multidisciplinary
deliberate self-harm.
detoxification.
team deem to be suitable
Patient deemed unable to
Physical disabilities which
Patients who are willing to assume
participate due to lack of
prevent SAM.
responsibility for their medication
capacity as defined under the
Reduced cognitive capacity
Mental Capacity Act (2005).
Patients who will assume
responsibility for taking their
Patients who will not be selfmedication at home
medicating upon discharge.
Patients who are on a stable
medication regime
The medicines appear to be in good condition 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 in doubt, pharmacy staff can be asked to assess the suitability of the medications
The following must also apply: The drugs are prescribed on the hospital prescription chart in the same dose, timing and method of
administration as labelled on the packaging.
The patient has consented to use his own medications whilst in hospital.
Each item for self-administration must be endorsed SAM in the Other instructions/Indication box on the
prescription chart, and the SAM assessment box completed on the front of the chart
Assessment of patients own medications
Please circle yes or no
Has patient consented to the use of his/her own medications?
Yes
No
Yes
No
Yes
No
Comments
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APPENDIX 2
APPENDIX 3
SAM Quick Reference Guide
Ordering, Prescribing, Administration & Documentation
Ordering :
All medication in the patients 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 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.
Documentation:
For self-administered items, the nurses will write SAM in Indication and Other Instructions
Book on the drug chart. Administration of other items will be documented in the usual way.
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APPENDIX 4
Yes
Assess Patients Own Medications
for suitability
(POD Flowchart- Appendix 12)
If
undeliverable
Educate patient on the implications of SAM and provide access to the bedside
locker if Level 3
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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Appendix 5
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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. You may
be able to keep certain rescue medicines (eg angina sprays or
inhalers for asthma) outside of the locked cabinet if appropriate. The
nurse will discuss this with you. 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.
www.peninsulacommunityhealth.co.uk
PLEASE REMEMBER
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APPENDIX 7
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
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:
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
DOB
Special Notes
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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)
APPENDIX 8
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:
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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
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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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
Sheet No.. of
PATIENT NAME:
WARD:
NHS / CR NO:
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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Sheet No.. of
PATIENT NAME:
WARD:
NHS / CR NO:
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
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Number
Issued
Actual
Amount
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APPENDIX 11
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Appendix 12
Assessing Patients 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
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
Inhalers
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Appendix 13
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APPENDIX 14
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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
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APPENDIX 16
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