Duties and responsibilities are outlined for both staff and patients during the process of self-administration of medicines (SAM)


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
  • record any changes in the medical 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 and the pharmacy team
  • discuss with the individual any changes to their medicines
  • be alert to an individual’s ability to administer their own medicines

Heads of Nursing and Matrons

Working in line with the organisation’s medicines policy, Matrons and Head of Nursing should:

  • ensure ward sisters/charge nurses are aware of the self-administration of medicines policy, their responsibilities within it and any barriers to implementation
  • support regular review of SAM within their clinical area, monitoring medication incidents and acting on identified issues
  • feedback to the responsible medicines governance committee
  • ensure all procedures written in the policy for self-administration are followed

Ward Sister/Charge Nurse

Working in line with the organisation’s medicines policy, the ward sister/ charge nurse should:

  • ensure safety measures are in place to allow self-administration of medicines to take place. Consideration should be given to safe storage, key access, etc.
  • ensure all relevant ward team members are trained and are capable of identifying patients who are and are not able to administer their own medicines
  • ensure all ward team members are aware of their roles and responsibilities of caring for individuals who are self-administering their medicines
  • monitor, review and act on medication incidents, including those involving self-administration of medicines

Registered Nurses

Working in line with the organisation’s medicines policy, registered nurses should:

  • complete training on how to assess an individual’s suitability for SAM and maintain competence, discussing any concerns with the ward sister/charge nurse
  • assess individuals as able to continue to administer their own medicines, or not able to do so, using the criteria and process detailed. This will include assessment of mental capacity for adults or legal competence for children
  • provide support to the individual regarding their medicines. This includes a general understanding of their medication, with more specific requirements for certain medicines
  • if a carer is involved in the administration of medicines for the individual at home, ensure that the individual’s carer is competent to administer medicines and there are no known safeguarding issues
  • reassess the individual’s ability to administer their medicines if their condition, ability or mental capacity for SAM change, acting upon any concerns which may affect patient safety. This assessment could routinely take place when undertaking other patient observations, e.g. blood pressure
  • ensure the individual is able to access their medicines kept securely locked away at all times. Exceptions to secure storage may be made where previously agreed and risk assessed e.g. reliever inhalers, glyceryl trinitrate (GTN) spray, insulin
  • ensure the individual is aware of changes made to their medicines and that the medicines are suitable for use
  • ensure the individual records the medicines they are taking, in line with the process defined

Pharmacy staff

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

  • 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
  • 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 during their hospital admission. This includes that the patient’s own medication (PODs) are correctly labelled and suitable for continued use and/or that medicines are individually dispensed
  • 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


Individuals and/or their carers should:

  • agree to the conditions laid out in the self-administration policy
  • read the patient information leaflet 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. Notify staff immediately of any missed doses or incorrect doses taken
  • store their medicines securely, with appropriate access

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