Overview

Self-administration of medicines (SAM) is the responsibility of all staff and individuals. However, different staff groups may have defined responsibilities depending on the local skill mix; responsibilities should be defined within the local organisational policy or procedure for self-administration.

Prescribers

Working in line with the organisation’s medicines policy prescribers should:

• ensure that any changes to an individual’s medicines are accurately and clearly recorded on the prescription chart or within the clinical record if MAR chart or a direction to administer are being used – see
• record any changes in the clinical notes along with the reasons for those changes
• inform relevant colleagues looking after the individual of any changes in medication, such as the named nurse, the pharmacy team and feedback to multidisciplinary team (MDT)
• discuss with the individual any changes to their medicines and advise individual that any new or changed medicine will be supplied or re-labelled
• be alert to an individual’s ability to administer their own medicines and consider any adaptations that might be required (e.g. different inhaler device)

Heads of Nursing and Matrons

Working in line with the organisation’s medicines policy, matrons and heads of nursing should:

• ensure service managers/clinical leads/charge nurses are aware of the SAM policy, their responsibilities within it and any barriers to implementation
• support regular audit of SAM within their clinical area, monitoring medication incidents and acting on identified issues
• feedback any concerns to the responsible medicines governance committee
• ensure all procedures written in the policy for SAM are followed

Ward Manager/Clinical or Service Lead/Charge Nurse

Working in line with the organisation’s medicines policy, the ward manager/clinical or service lead/charge nurse should:

• ensure safety measures are in place to allow SAM to take place and consideration should be given to safe storage, secure access methods, etc.
• ensure all relevant team members are trained and are capable of identifying individuals who are and are not able to administer their own medicines
• ensure all team members are aware of their roles and responsibilities when caring for individuals who are undertaking SAM
• monitor, review and act on medication incidents involving SAM

Registered nurses and other healthcare professionals supporting SAM

Working in line with the organisation’s medicines policy, registered nurses or other healthcare professionals within the organisation supporting SAM should:

• complete training on how to assess an individual’s suitability for SAM and maintain competence, discussing any concerns with the ward manager/clinical or service lead/charge nurse
• assess individuals as able/not able to continue, or where relevant begin, to administer their own medicines using the criteria and process detailed; this will include assessment of mental capacity for adults or legal competence for children
• provide support to individuals regarding their medicines; this includes a general understanding of their medication, with more specific requirements for certain medicines
• if carers are involved in the administration of medicines for individuals at home, ensure that each carer is able to administer medicines and there are no known safeguarding issues
• routinely monitor individuals undertaking SAM and reassess each individual’s ability to administer their medicines if their condition, ability or mental capacity for SAM change, acting upon any concerns which may affect safety; this assessment could routinely take place when undertaking other observations, e.g. blood pressure
• ensure individuals undertaking SAM are able to access their medicines and that these are kept securely locked away at all times: note exceptions to secure storage may be made where previously agreed and risk assessed e.g. reliever inhalers, glyceryl trinitrate (GTN) spray, insulin
• where relevant ensure individuals understand any changes made to their medicines and that the medicines are correctly labelled with new directions/have been supplied and are suitable for use
• ensure individuals records the medicines they are taking, in line with local policy/procedure (noting some polices may require staff to also record administration)

Pharmacy staff

Working in line with the organisation’s medicines policy, pharmacy staff should:

• complete training on how to assess an individual’s suitability for SAM and maintain competence, discussing any concerns with the department lead
• complete medicines reconciliation: this includes consideration of any medicines related reason for admission and whether the individual manages their medicines independently at their usual place of residence.
• consider possible use of any medicines that may have been purchased without the involvement of a regular prescriber or via a pharmacy (e.g. medicines purchased online).
• as part of medicines reconciliation, assess the ability of an individual to continue to administer their own medicines, using the criteria and process detailed
• check the individual has the medicines they need: this includes that the individual’s own medication (PODs) are correctly labelled and suitable for continued use and/or that medicines are individually dispensed and labelled with the correct directions for use
• liaise with nursing and medical staff if they have any concerns regarding an individual’s ability to continue SAM
• participate in discharge planning to help communicate safe transfer of medication details to community colleagues and ensure that a continued supply of medication and support is available to the individual

Note in some services where there is no embedded pharmacy team some of the above responsibilities may lie with other trained and competent healthcare professionals. Where relevant this should be reflected in local policies/procedures.

Individual/Carer

Individuals and/or their carers should, in line with local policy/procedures:

• agree to the conditions laid out in the self-administration policy
• read the SAM information leaflet (where locally available) and sign the consent section on the assessment form
• notify staff, where able, of any changes in their condition that may impact on their ability to self-administer and notify staff immediately of any missed doses or incorrect doses taken
• store their medicines securely

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