[insert organisation name/logo]
Client Medication Management Policy
Document Status:
Draft or Final
Date Issued:
[date]
Lead Author:
[name and position]
Approved by:
[insert organisation name] Board of Directors on [date]
Date for Review:
[date]
Record of Policy Review:
Date Policy
was Issued
[month, yr]
Date of
Review
[month, yr]
Reason for Review
[for example, incorporate changes
to new legislation]
Client Medication Management Policy – [month/year]
Lead
Reviewer
[name]
Additional Comments
[for example, policy
now covers details
related to new
legislation].
Page 1 of 10
Client Medication Management Policy
1.
Purpose and Scope
The purpose of this policy is to provide guidelines for [insert organisation name] in
the provision, storage, administration and disposal of medications.
This policy applies to all staff who are responsible for handling or dispensing of
medications.
This policy does not provide detailed information on specific types of medications, the
effects of medication interactions or side effects of medication.
2.
Definitions
Medication compliance aids assist clients to organise and/or take their medication.
These include: blister packaging (with each ‘blister’ containing medication needed at
a specific medication administration time) and medication boxes.
Prescription only medication refers to any medication listed in Schedule 4 or
Schedule 8 of the NSW Poisons List and which is only available to the public on
prescription by a medical practitioner or dentist.
PRN medication is medication required “as needed”, with particular conditions and
limits.
Stock medication refers to medication which has not been individually dispensed for
a client by a pharmacist on prescription.
Schedule 4 drugs and poisons (also known as prescription only medications) are
substances and preparations supplied only on prescription and require professional
monitoring.
Schedule 8 drugs (also known as Controlled Drugs) are substances and preparations
for therapeutic use which have high potential for abuse and addiction.
3.
Principles
Medications are for the purpose of treating or preventing a health condition and are
to be used strictly in accordance with their prescribed instructions.
The handling and use of medications is to be compliant with the relevant legislation
and practice guidelines.
Client Medication Management Policy – [month/year]
Page 2 of 10
Staff have a duty of care to ensure client safety and the proper use of medication.
Failure to satisfy this duty of care adequately may lead to [insert organisation
name] and its staff being held responsible in the event of a mishap.
4.
Outcomes
[name of organisation] will be safe, competent and legal in all its medication
transactions for the protection of clients and staff.
Clients are supported, to the degree required, to take prescribed medication.
5.
Functions and Delegations
Position
Board of Directors
Delegation/Task
Endorse Client Medication Management Policy.
Compliance with Client Medication Management Policy
Management
CEO/Manager
Monitor implementation
Management Policy.
and
review
Client
Medication
Ensure staff are competent regarding medications legislation
and work practices.
Collate/report information on adverse events as required.
Ensure staff, receive appropriate training, supervision.
[insert position]
Provide support to supervisors, staff, students and volunteers as
required.
Staff
Compliance with Client Medication Management Policy.
Registered Nurses/Medical Practitioners
Maintain knowledge of current good practice related to
medication management.
6.
Risk Management
Systems are in place to ensure information about client medication is accurate and
current.
Client Medication Management Policy – [month/year]
Page 3 of 10
All client medication is kept in a secure place that cannot be accessed by
unauthorised people.
[name of organisation] ensure that staff who assist clients managing their
medications are aware of relevant legislation and duty of care provisions through
induction, training and an assessment of their competencies prior to undertaking
these duties.
This policy will be reviewed in line with the organisation’s quality improvement
program and/or relevant legislative changes.
7.
Policy Implementation
This policy is developed in consultation with all employees and endorsed by the
Board of Directors.
This policy is to be part of all staff orientation processes and all employees,
volunteers and students are responsible for understanding and adhering to this
policy.
This policy should be referenced in relevant policies, procedures and other
supporting documents to ensure that it is familiar to all program staff and actively
used.
8.
Policy Detail
Clients are primarily responsible for managing and taking their own medication.
Where a client is not capable of managing his/her medication, and where a client’s
medication has been individually dispensed and packaged for them on prescription,
an [insert organisation name] employee may provide assistance to support the
client to take their own medication.
Clients are not permitted to be involved in the provision of medication to other clients.
8.1
Admission
On admission to [name of organisation] all clients are required to surrender all
unfilled prescriptions, medications (including prescription and non-prescription,
medications, vitamins and herbal remedies) to staff. The exception to this rule is the
use of an inhaler which the client may keep on their person.
Client Medication Management Policy – [month/year]
Page 4 of 10
All clients taking prescription medication while at [name of organisation] must
provide a letter from their prescribing doctor outlining; the client’s condition,
treatment, medication instructions and the stability of the condition.
Clients using vitamins or herbal remedies must only bring unopened packages that
will be assessed by [insert position]. Any items that cannot be positively identified
will be disposed of.
Staff providing assistance to clients in managing their medication ensures the
pharmacy label on the original dispensed container corresponds with the Client
Medication Record in the client file, including:
- Client’s name
- Name and strength of medication
- Dosage and time
- Directions for use.
Any medication taken by the client must be recorded on the Client Medication
Summary and signed by both client and staff.
In the event that verbal instructions from the client or carer regarding how the
medication is to be given differs from those on the pharmacy label, or there are
insufficient directions on the label, the client is required to provide staff with a letter
confirming the correct instructions from the prescribing doctor.
If there is any doubt that the medication is current and that the dosage as stated on
the pharmacy label remains correct, the prescriber or the dispensing pharmacist
must be contacted for clarification. If these professionals are unavailable staff seek
advice from the Poison Information Centre on 131126.
8.3
Medication Records
A list of current prescribed medication is kept for all clients using the Client
Medication Summary, in each client’s file. The Client Medication Summary is to be
completed by the client’s doctor and updated whenever a medication is changed.
Staff maintain a record of prescribed medication taken by clients on the Client
Medication Record which is signed by the client and the staff member when the
medication is taken.
Additionally, when staff support a client to take a prescribed PRN medication, a note
of the dose taken and the time taken is made in the Client Medication Record.
8.4 Dispensing Medication
Client Medication Management Policy – [month/year]
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The medication is to be taken from the original dispensed container by the client at
the prescribed time.
Staff must observe ingestion of the medication by the client.
All tablets and capsules should be swallowed whole unless a pharmacist or doctor
advises otherwise. If in doubt consult the pharmacist /prescriber.
Injections may only be administered by a medical practitioner or registered nurse.
This does not preclude a client self-administering their own insulin as required.
[insert position] record medication administered to the client on the Client
Medication Record. The client and the staff member sign the medication record after
medication has been administered.
8.5
Medication Compliance Aids
Blister Pack
Staff assist clients to take medication from a blister pack which has a pharmacy label
attached by handing over the blister pack and observing the client taking the
medication.
Medication Box
Medication boxes are utilised by clients for their own use in self-administering their
medication. Medication boxes are generally filled by the pharmacist dispensing the
client’s prescription (unless the client is able to safely load the ‘box’ him/herself).
A medication box must not be filled for a client by any person other than a
pharmacist, a medical practitioner or a registered nurse.
The medication prescriber must provide written confirmation of any change in
medication and/or dosage to the pharmacist or registered nurse.
8.6
PRN Medication
In the event of a client being prescribed a PRN medication, clear and precise written
directions must be obtained from the Doctor covering:
- Circumstances under which the drug or medication must be given
- Procedure for administration
- Circumstances under which a further dose can be administered and what is
considered a safe interval between doses
- The maximum PRN dose
- Circumstances in which the doctor must be notified
Client Medication Management Policy – [month/year]
Page 6 of 10
The written instructions are included on the Client Medication Summary in the client
file.
PRN medication will be administered according to the Doctor’s written instructions
and will only be given after authorisation from [insert position].
Staff record the date, time and dosage when providing support to clients using PRN
Medication and ensure that the client does not exceed the prescribed 24 hour
dosage.
Administration of PRN medication will be recorded on the Client Medication Record.
Records of PRN medication administration should be taken to the prescribing doctor
at the next appointment.
8.7
Non Prescription Medication
Non prescription medication maybe taken by clients on the premises and will be
administered as directed on the package. If symptoms persist, staff will offer support
to the client to make a Doctor’s appointment.
8.8
Non-Compliance
A client must not be forced to take medication against his or her wishes. However,
every effort must be made to give medication as prescribed.
If a client decides not to take their prescribed medication, the staff member providing
medication support must:
- Ask the client why they do not wish to take their medication
- Explain to the client the reason for taking the medication and the possible
effects on their health if medication is not taken
- Encourage the client to speak with the prescribing doctor before making a
decision to stop medication
- Contact [insert position] to advise of the client’s non-compliance with the
prescribed medication.
- If required, the prescribing doctor is contacted for instructions. If the doctor is
unavailable, call the after-hours doctor, pharmacist or Poisons Information
Centre.
- Observe the client for changes in behaviour or well being and report these to
the [insert position] and/or doctor
- Record all details in the Client File.
8.9
Medication Error
Client Medication Management Policy – [month/year]
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If it is known that a client has missed a dose, has taken the wrong medication, or
appears to be suffering an adverse reaction, the medication error must be recorded
on an Incident Report Form (copy to be placed in client’s file) and the client’s GP
contacted and informed of the error.
The Poison Information Centre, phone - 13 11 26, may need to be notified if the client
has taken the wrong medication or appears to be suffering an adverse reaction.
If there is concern for a client’s safety and health, including when a medication
overdose is suspected or known, the client must be transported to the nearest
Accident and Emergency Department. If required, request an ambulance via the
emergency services, phone – 000.
A copy of any Incident Report relating to medication errors is put in the medication
section of client’s file.
8.10 Disposal of Medication
Any clients’ medication on [insert organisation name] premises, that is no longer in
use, must be destroyed. It must not be used by, or for, another client or kept and
allowed to accumulate with other client’s medication.
Medication must be disposed of safely and in a manner which is not harmful to the
environment. Staff are to record the medication name, client’s name and the amount
of medication to be destroyed and advise the [insert position] that there is
medication for disposal. Medication to be destroyed should be sent to the local
pharmacy for safe disposal.
8.11 Storage of Medications
Client medications are held at [insert location]. All client medication is to be stored
in this location.
The medication cabinet is securely locked at all times in a room with limited access
for clients and staff.
Access to the medication cabinet is restricted to appropriate personnel who are
administering medication.
For home visits, the [insert position] must carry the client’s original dispensed packs
to the client’s home where the medication will be directly administered.
8.12 Medication Audit
Client Medication Management Policy – [month/year]
Page 8 of 10
Monthly medication audits by the [insert position] will check that:
- Prescriptions held at [insert organisation name] premises are current
- Medication use-by dates have not expired (including ointments and creams)
- Medication containers are original dispensed containers and not damaged
- Storage procedures are correct
- Client Medication Summaries are complete and current
- Client Medication Records are complete.
Any anomalies or medication for disposal should be reported immediately to the
CEO/Manager.
9.
References
9.1
Internal
Client Medication Summary
Client Medication Record
Incident Report
Occupational Health & Safety Policy
9.2
External
Legislation
Poisons and Therapeutic Goods Act 1966 (NSW)
Poisons and Therapeutic Goods Regulation 2008 (NSW)
Resources
NSW Health, 2007, Drug and Alcohol Treatment Guidelines for Residential
Rehabilitation Settings, NSW Health, Sydney.
NSW Health, 2005, Medication Handling in Community Based Health Services /
Residential Facilities in NSW Guidelines, NSW Health, Sydney.
9.3
Quality and Accreditation Standards
EQuIP4
Provided by the Australian Council on Healthcare Standards (ACHS)
Standard 1.5: The organisation provides safe care and services.
Criterion 1.5.1: Medications are managed to ensure safe and effective practice.
Client Medication Management Policy – [month/year]
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Health and Community Service Standards (6th edition)
Provided by the Quality Improvement Council (QIC)
Standard 2.2: Services and programs are provided in an effective, safe and
responsive way to ensure positive outcomes for consumers and communities.
Evidence questions: What is the evidence that:
f) service and clinical governance systems are in place?
m) client and community outcomes are documented and clear, accurate and secure
client and program records are kept?
o) incidents, adverse events and near misses are reported, and reports are used to
inform improvements?
Client Medication Management Policy – [month/year]
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