Self Medication policy (MHS MRG 56)

This programme is for use within Mental Health inpatient services across NHS Greater Glasgow
& Clyde.

Self-medication programmes are a practical method of improving patient involvement and
control of medicine administration prior to discharge from hospital. Patients should gain a better
understanding of their medication while retaining or improving independence.

The main aims of the programme are:

• To establish a standard process for determining the ability of patients to take their own
  medication reliably and safely.
• To encourage patients to be more independent and take responsibility for their own medication within their individual limitations.
• To assess patient concordance and where necessary improve it through education and self-administration of their medication.

All patients may be considered, however, those undergoing rehabilitation into the community
will be prioritised.

The ward multi-disciplinary team (MDT) will identify patients potentially suitable for self-medication and be responsible for co-ordinating the programme for each individual patient.

The following should be considered:

• Patients should be stable on their current medication, which is not expected to change.
• Patients on regular controlled drugs, benzodiazepines or night sedation are excluded from participation in the self-medication programme. Exceptions to this are patients on controlled drugs that do not have safe custody storage and recording requirements e.g. tramadol, pregabalin, gabapentin.
• As required medicines (‘PRNs’) will not be included in the self-medication programme. As required medicines will continue to be administered at the discretion of nursing staff.
• Medication should be reviewed and, where possible, simplified prior to commencing the self-medication programme.
• Only patients who are motivated and willing to accept responsibility should participate.
• Medical and nursing staff will have knowledge of the patients’ medical/psychiatric/social history, medication prescribed and be aware of the risks involved for each individual patient.
• A lockable secure cupboard must be available for each patient to store his or her medication (stage 1 of the programme and above). If individual lockable cupboards are not available alternative options involving storage within ward treatment rooms or suitable drug trolley should be discussed with Pharmacy.
• Staff must have knowledge of NHSGGC policies concerning the ordering, storage, and safe administration of medicines, as well as this self-medication policy. (Medicines Administration V2 Update)

An initial patient assessment for self-medication must be completed prior to commencement of the programme. (Appendix 1)

This assessment should be carried out by the named nurse in consultation with the patient and, if available, the pharmacist.

The patient information leaflet (Appendix 2) will be provided, and more written information should be provided if required.

The assessment is then presented to and discussed by the multidisciplinary team (MDT).

The following people should normally be involved:

• Patient
• Consultant Psychiatrist
• Named Nurse
• Senior Charge Nurse
• Ward Clinical Pharmacist or Pharmacy Technician
• Occupational Therapist

The MDT will then decide if the patient is suitable to commence the programme and the decision documented on the assessment form and in the patient’s chronological account of care.

When a patient is considered for the programme, following assessment and discussion by the
MDT, the patient must give their written consent by signing the assessment form.

If possible, the assessment will identify the post discharge location for the patient. It is
acknowledged that some care providers insist upon disposable blister packs (e.g. Dosettes) as
the preferred format for supervision purposes and therefore these would be dispensed from the
outset.

After all pre-assessment documentation has been completed the named nurse in consultation
with the patient will compile a care plan, specific to their individual needs. The care plan will be
reviewed and updated regularly by nursing staff.

A Medication Chart should be completed by the named nurse or pharmacist or pharmacy
technician and issued to the patient (Appendix 5). This will need to be updated if medication is
changed.

Supplies for self-medication will be individually dispensed for patients by the pharmacy
department. Ward stock supplies should never be used for this purpose.

A pass medicines request form (pass ordering procedure) should be sent to pharmacy who will
print a copy of the patient’s Medicines Administration Chart (MAC) from HEPMA, detailing all
the medication required by the patient to self-medicate on the ward.

The following information should also be written on the pass request form:

• ‘For self medication programme stage____’
• Request for medication supply to be repeated weekly.
• Any specific requests e.g. compliance devices (if assessed as necessary)

All patients will commence on stage 0 pending assessment.

When patients commence the self-medication programme, a note should be added to the
patient’s HEPMA profile highlighting they are part of the programme and at what stage they are
currently working.

Medication prescribed on HEPMA will need to be amended by a prescriber to allow for self-administration to be charted by nursing staff at medication rounds.

1. Right click on the medication prescribed.
2. Select ‘Order Modify’
3. Under ‘Medicines Management,’ select ‘will self-administer this drug.’
4. Confirm change.

This process will need to be repeated for each medication prescribed, and for newly started
medication.

Where the patient is found to have problems in taking their medication, they may be held at a
particular stage until the problems are resolved, and improvement is observed. They may also
be withdrawn from the programme altogether. The MDT may also decide to maintain a patient
at one stage indefinitely. If withdrawn from the programme, each medication will need to be
amended on HEPMA again, and the ‘will self-administer this drug’ box unchecked.

The nurse in charge of the ward can decide to suspend or return the patient to the previous
stage of the programme at any time of day or night. This action and the patient’s current stage
on the programme must be reviewed at the next MDT meeting.

There are four stages of the programme (summarised in Appendix 4). Patients will commence
on stage 0 and progress to the next stage if appropriate following review by the MDT. The
consultant and named nurse or senior charge nurse must approve a patient’s progression from
one stage to the next. Stage 0 is applicable to all settings. If individual patient medication
lockers are unavailable, patients will not progress through the stages as described below
but instead stage 0 will be locally adapted to reflect the facilities available in the wards
concerned.

• A seven-day pass prescription should be ordered from pharmacy, checked and securely
  stored in the drug trolley by nursing staff.
  N.B: Any discrepancies must be notified to the pharmacy department immediately and the
  medication supply returned to be re-dispensed.
• Patient should be advised to report independently to the drug trolley and administer medication under supervision.
• Administration will be monitored by nursing staff who will check, and record medication taken
  on HEPMA. A ‘non-administration’ drop-down menu will appear when charting, and ‘Self-Administered’ should be selected.
• During Stage 0 the nurse’s electronic signature indicates they have ensured the patient has
  requested, selected, and taken his or her own medications according to the instructions on
  the label, which must be consistent with HEPMA.
• Should the patient fail to request medication at the due time, the nurse should seek out the
  patient, assess and document the reason for failure and administer the appropriate
  medication. Any failure to request medication should be referred back to the MDT.
• A follow-up assessment report (Appendix 3) should be compiled by the Named Nurse for
  discussion at the MDT meeting prior to the patient moving on to stage 1. This assessment
  should include assessing competence in managing medication and any dexterity problems. If
  there are any identified problems during Stage 0, consideration should be given to referring
  to the pharmacist and/or the occupational therapist for advice/input.

• A seven-day pass prescription should be ordered from pharmacy, checked and securely
  stored in the patient’s individual locked cupboard.
  N.B: Any discrepancies must be notified to the pharmacy department immediately and the
  medication supply returned to be re-dispensed.
• The patient must approach nursing staff unprompted at the appropriate times, request the
  key for their locker, escort nursing staff to the locker, select the required medication and
  administer under nursing supervision. The key should then be handed back to nursing staff.
• Administration will be monitored by nursing staff who will check, and record medication taken
  on HEPMA. A ‘non-administration’ drop-down menu will appear when charting, and ‘Self-Administered’ should be selected.
• During Stage 1 the nurse’s electronic signature indicates that the nurse has ensured the
  patient has requested, selected, and taken his or her own medications according to the
  instructions on the label, which must be consistent with HEPMA.
• Should the patient fail to request medication at the due time, the nurse should seek out the
  patient, assess and document reason for failure and administer the appropriate medication.
  Any failure to request medication should be referred back to the MDT.
• Keys for self-medication lockers must be stored securely in appropriate location within the
  ward e.g. a self-medication box in the drug trolley in the treatment room.

• A seven-day pass prescription should be ordered from pharmacy, checked and securely
  stored in the patient’s individual drug cupboard by nursing staff.
  N.B: Any discrepancies must be notified to the pharmacy department immediately and the
  medication supply returned to be re-dispensed.
• Patient requests key for locker in the morning and keeps on person all day.
• The patient reports to nursing staff prior to accessing medication, nursing staff escort patient
  to their locker and the patient selects their medication whilst being supervised.
• Administration will be monitored by nursing staff who will check, and record medication taken
  on HEPMA. A ‘non-administration’ drop-down menu will appear when charting, and ‘Self-Administered’ should be selected.
• During Stage 2 the nurse’s electronic signature indicates that the nurse has ensured the
  patient has requested, selected, and taken his or her own medications according to the
  instructions on the label, which must be consistent with HEPMA.
• Should the patient fail to request medication at the due time, the nurse should seek out the
  patient, assess and document reason for failure and administer the appropriate medication.
  Any failure to request medication should be referred back to the MDT.

• A seven-day pass prescription should be ordered from pharmacy, checked and securely
  stored in the patient’s individual drug cupboard by nursing staff. N.B: Any discrepancies must be notified to the pharmacy department immediately and the medication supply returned to be re-dispensed.
• The nurse creates a patient note on the patient’s HEPMA profile to document when supplies
  were given to the patient. This should be updated each week with each supply.
• The patient takes his or her own medication without observation or supervision from a nurse.
• At each medication round on the ward, HEPMA will prompt nursing staff to administer
  medication as normal. This should be documented as ‘Self-Administered’ under the ‘non-administration’ drop-down menu as before.
• Patient should be encouraged to use the Patient Medication Tick Chart (Appendix 6) to
  document when they have taken their medication, using their Medication Chart (Appendix 5)
  to aid them.
• Spot checks must be conducted at nurses’ discretion at least twice per week to monitor
  patient compliance. Each spot check must be recorded on HEPMA under a patient note.
  Record of spot checks and the result should also be noted in the patient’s chronological
  account of care. A spot check involves counting the number of tablets and checking that this
  is the correct amount for the remainder of the week. If the patients’ medication is in a blister
  pack the spot check should also ensure that the remaining days and times are correct.
• During spot checks, if any discrepancies/missed doses are identified they must be clearly
  documented in the patient’s notes on HEPMA and in their chronological account of care. It is
  not currently possible to amend a dose that has been missed by the patient when it has
  already been documented as ‘self-administered’ on HEPMA.

• As Stage 3, but patient collects supply of medication from the pharmacy department. This is
  only possible if there is a pharmacy department or clinical office on site and collection from
  those is assessed as safe and appropriate.
• The decision to move to this stage should be risk assessed on an individual basis.
• Prior to this stage, the patient must be taken to the pharmacy to orientate them to the
  department and introduce them to pharmacy staff.
• Each time the patient presents to pharmacy to collect their medication, they should take the
  medication supply and receipt form (Appendix 7). The staff member at pharmacy supplying
  the medication will sign to state that medication has been given to the patient and the patient
  will sign in receipt of the medication.
• When patient returns from pharmacy with their supply of medication, nursing staff must sign
  the form to receive medication and in doing so, must check the contents to ensure that the
  medications and directions on the label correspond to what is prescribed on HEPMA.
  N.B: Any discrepancies must be notified to the pharmacy department immediately and the
  medication supply returned to be re-dispensed.

Pharmacy should be notified immediately of any changes or discontinuations to a patient’s
medication. Once notified, pharmacy staff will print an updated copy of the patient’s Medicines
Administration Chart from HEPMA.

If any medication changes are made before the next supply is due (usually every Friday), the
following should apply:

• Consider if the change is urgent or can wait until the next self-med supply is due.
• Dose increases and or new medication added for patients who receive their self-meds in disposable blister packs and for patients that receive their self-meds in skillets/bottles- a new labelled supply in skillets/bottles giving a top-up dose or a supply of the new medication will be provided, that should last until the new weekly supply is sent.
• Dose decreases for patients who receive their self-meds in skillets/bottles– will receive a new labelled supply with the decreased dose that will last until the new weekly supply is sent. The skillet/bottle containing the old dose should be removed by nursing staff and placed with the “returns to pharmacy” items, prior to being returned to pharmacy for destruction.
• Dose decreases for patients who receive their self-meds in disposable blister packs- nursing staff should remove the disposable blister pack and place it with their “returns to pharmacy” items, prior to being returned to pharmacy for destruction. The self-medication program should be suspended until the new amended weekly supply is received from pharmacy (usually every Friday). The patient should have their medication administered by nursing staff from ward stock supplies until the new disposable blister pack is received.
• Discontinued medication for patients who receive their self-meds in skillets/bottles– nursing staff should remove the discontinued medication skillet/bottle from the patients supply and place it with their “returns to pharmacy” items, prior to being returned to pharmacy for destruction.
• Discontinued medication for patients who receive their self-meds in disposable blister pack– nursing staff should remove the disposable blister pack and place it with their “returns to pharmacy” items, prior to being returned to pharmacy for destruction. The  self-medication program should be suspended until the new amended disposable blister pack weekly supply is received from pharmacy (usually every Friday). The patient should have their medication administered by nursing staff from ward stock supplies until the new disposable blister pack is received.
• Patients with medication changes, who are leaving the ward to go out on pass– please contact pharmacy and arrange for the current self- medication supply to be returned to pharmacy for re-dispensing. The changes will be made and a new supply issued.
• All the above changes will be made subject to stock availability and usual workload/delivery cut-off times.

A change in the stage of the programme may be notified to pharmacy by telephone.

Nursing / Medical staff must never make any amendments to the dispensed medication supply.
If a change is required pharmacy must be notified.

Where continual changes to a patient’s medication are necessary, for example if the patient is
acutely ill, the self-medication programme should be suspended until the prescribed medication
stabilises again.

Patients must be encouraged to keep their key safe (stages 2 onwards). If a patient loses their
key, consideration must be given to moving back to the previous stage of the self-medication
programme.

Loss of medication must be reported to the nurse in charge who will investigate and take
appropriate action. Depending on the circumstances, this may include contacting the on-call
senior charge nurse, pharmacist, or the police.

Passes

Medication labelled and supplied to self-medicating patients may be used as pass medication
and must be brought back to the hospital on return from pass.

Alternatively, pass medication for the duration of the pass can be ordered from pharmacy if
there is risk of patient not bringing medicines back to the ward following a period out on pass.

Discharge

A community pharmacy must be identified with capacity to provide ongoing weekly or monthly
supplies on discharge, especially for patients using disposable blister packs.

As clozapine will continue to be dispensed from Leverndale pharmacy on discharge, patients
using disposable blister packs receive clozapine in one device and their remaining medicines in
another device.