When medicines are prescribed for use ‘when required’ there must be systems in place to ensure that stock is kept at safe levels and to prevent medication being given that has expired.
For the prescribing of ‘when required’ medicines include all relevant information to allow staff to administer the medicine to assist the carer.
Where there is a choice of dosages for a patient’s medication, for example, 1-2 to be taken…further guidance is required from the GP or pharmacist to clarify the situations in which one dose should be given and those in which two doses should be given, the time between doses and the signs that indicate that a further dose may be required.
It is recommended that all homes develop clear individualised ‘prn protocols’ for each ‘when required’ medicine so that staff are clear of the reasons for each prescription for each resident and the symptoms to look out for.
For example,
- one to be taken when required to aid sleep. What does this look like e.g. if the person is still awake after 2 hours?
- if instructions say take one or two when should you give one and when should you give two?
- if the individual is non-verbal how do you know when they require the medication? For example, if the medication is prescribed take for agitation what does that look like? How does the individual express pain? Do they rock or hold their sides?
- what is the maximum dose in 24 hours? NICE and pharmacy guidelines indicates that a maximum dose in 24 hours or per episode must be stated on the label.
- if there is any doubt about the dose schedule for a ‘when required’ medicine this should be clarified with the GP or pharmacist. This is to enable a personalised medication plan to be developed
It is difficult to predict how much ‘when required’ medication a patient will need in the 28 day cycle. This can result in significant amounts of medication being wasted only for a replacement supply to be reordered the following month. Procedures must therefore be set up and adhered to prevent wastage of when required medicines.
It is acceptable for homes to retain ‘when required’ medicines and carry these forward onto the next MAR sheet each month, dependent upon expiry dates.
It is best for PRN medicines to be dispensed in original containers. Medicines that have been dispensed for residents in their original packaging may be retained until the expiry date printed on the pack or strip, providing the PRN medicines is being given for the original condition for which the prescription occurred.
Further advice about expiry dates of ‘when required’ medicines, creams and liquids can be found at the
The electronic medicines compendium (emc)
External link.
If PRN medicines are dispensed into a monitored dosage system (tray/ blister) then a two month shelf life is usually given, after which the medicines will need to be replaced. This can be discussed with the community pharmacy as it may be more appropriate to have these items dispensed in their original packaging.
(Not recommended for care home residents)
If PRN medication is regularly being returned for disposal, ask the GP to prescribe smaller quantities and ask the community pharmacy to supply them in original containers.
Regular prescriptions
Regular medicines should be ordered together, once monthly to reduce the risk of errors.
Any unused doses (e.g. where odd doses have been refused or not taken or where medicines have been discontinued or changed) should be disposed of appropriately. Residential homes should have these medicines collected by the dispensing pharmacy whilst nursing homes will have a contract with a waste disposal company who will collect their medicines and other clinical waste.
If medication is left at the end of a cycle but the MAR sheet has been signed showing all doses have been given this should be investigated by the unit manager to find out why.
It is acceptable to ‘carry over’ regular medicines where there is a suitable supply left and the items are within their expiry date, or where failing to carry the supply over will leave a patient without medicines.
When carrying forward regular medicines, always check the expiry date on the packaging. Monitored dosage systems, however, usually only have a two month shelf-life because of medication stability.
The NICE guidelines 2014 for ‘Managing medicines in care homes’ concluded that ‘provided the medicine is still currently prescribed, is within its expiry date, and is still in its original container, and the manufacturer’s literature does not specify a short shelf life when the product is opened, there is no requirement for the medicine to be disposed of early and it should be carried forward to the next 28-day supply cycle’. This is particularly important when considering the expiry dates of creams/ ointments once opened.
If information on a recommended shortened expiry date cannot be found in the Patient Information Leaflet, an expiry date of 12 months, once opened, should be followed for topical preparations. Alternately the information can be accessed on the
The electronic medicines compendium (emc)
External link.
Acute and interim prescriptions
- GPs should prescribe the amount likely to be needed.
- GPs and pharmacists must record clear instructions on how the medicine should be used, how long the resident is expected to need the medicine, what the medicine has been prescribed for (use of ‘as directed’ is not acceptable under
Royal Pharmaceutical Society Guidelines
External link ) and a date of review.
- When an ‘acute’ prescription is started it should be clear to the care home that it is for a specified period of time.
- Ensure any records made on handheld portals or remotely are updated securely onto the patient’s clinical record e.g. smart phone or tablet with electronic care or electronic MAR systems
.
Ordering of medicines
Check stock and order only what is needed to cover the next 28 day cycle.
A photocopy should be taken of what has been ordered before sending the request to the GP surgery so any queries can be looked into.
Prescriptions will be generated by the surgery and then sent back to the home to be checked for any discrepancies against the record of what has been ordered. They should then be sent to the community pharmacist to be dispensed.
Care home staff should communicate with the community pharmacist if items need to be removed, any doses changed or new medications added.
If an item is no longer required by the service user, a further supply must not be ordered. It should be removed from the prescription list after consultation with the GP as appropriate, and removed from the MAR sheet by contacting the pharmacy.
In some cases an EPS (Electronic Prescription Service) may be used. This enables prescribers to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient’s choice. To send prescriptions via EPS there should be an agreement between care home, pharmacy and GP practice about how the scripts will be checked before they are dispensed.
Where EPS is used, the care home should be provided with a ‘token’ which should be checked against what has been ordered, prior to sending to the community pharmacist. In reality this will be a paper record of what was ordered when it is delivered by the pharmacy.
Ordering may also be done by the care home via an online ordering system. This method will reduce the potential for errors and discrepancies with orders to the GP practice. All care home staff involved in ordering online must be trained on how to use the system.
Method for carrying forward medication from one cycle to the next
The medication name, strength, formulation and dose of the medication must be transposed onto the new MAR sheet.
Discuss this with the community pharmacy. If they dispensed the original item they may be able to leave it printed on the new month’s MAR sheet without dispensing a further supply, with a note stating ‘not dispensed this cycle’ or similar.
The balance of tablets (or an estimation of liquids) carried over to the new MAR sheet must be written onto the chart to enable an audit trail to exist.
The entry (any handwritten entry) should be signed and dated and a witness should countersign the entry.
Risk Assessment/ Self-administration
The preferred option is always for an individual to manage their own medicines and a medication assessment should be completed by the care provider with the aim of maximising an individual’s independence in managing their medication.
The assessor should determine who else may be involved. This should be done individually for each person and should involve the person themselves, their family or carer, or care staff with the training and skills for assessment.
Care providers undertaking assessments should liaise with the pharmacist or GP to ensure that where possible, medicines are prescribed and dispensed appropriately in order for the person to retain their independence.
Self-administration of medicines is not an ‘all or nothing’ situation and a well done assessment will identify ways of improving independence possibly changing the format.
Homely Remedies
Homely or household remedies are also known as non-prescription medicines, which refers to medicines available over the counter in community pharmacies. These may be used in a care home for the short-term management of minor, self-limiting conditions. For example, cough, headache, indigestion etc.
There is a recognised duty of care by staff within a care home to be able to make an appropriate response to symptoms of a minor nature.
The GP should be informed of any non-prescribed medicines being taken by residents. This will ensure a complete profile of medication is included in their patient medication records to identify any interaction with prescribed medication or diet and monitor for possible adverse effects.
Most homely remedy policies held by care homes contain a list of the following items for care home staff to make an appropriate response to symptoms of a minor nature. These items should not be requested on prescription from GPs for short-term use of minor ailments:
- Paracetamol for occasional pain
- Indigestion remedies (e.g. magnesium trisilicate mixture)
- Constipation remedies (e.g. senna, lactulose)
- Remedies for diarrhoea (e.g. rehydration sachets)
- Cough remedies (e.g. simple linctus)
The non-prescribed medicines should be agreed locally with the GP and pharmacist and restricted to a limited list to reduce the risk of adverse reaction or interaction with prescribed medication.
A homely remedy policy held by the care provider should include:
- the limited range of remedies that are kept
- the indications for offering the medicines and the limit on duration of treatment
- the dose to be given and how often it can be repeated before referring to the GP
- how to establish with the GP that the remedy will not interact with other prescribed medicines
The GP should be informed if homely remedies are used for more than 48 hours and symptoms still persist. The MAR sheet should confirm this.
The administration of homely remedies must be fully recorded on the MAR sheet.
The care provider may request directions of use via a fax/ secure email from the GP to be transcribed by the carer onto the MAR sheet with a second accuracy check and signature.
Covert administration
A clear distinction must be made between those people who have capacity to refuse medication and whose refusal should be respected, and those who lack this capacity.
All principles about covert medication administration should be guided by the core principles of the Mental Capacity Act (2005).
See CQC guidance on covert medication here External link.
Use of Multi-Compartment Compliance Aids in Home Care
Multi-Compartment Compliance Aids (MCA) or Monitored Dosage Systems (MDS) or Dosette, as they are sometimes referred to, is a general term for a device designed to contain individual doses of medicines in separate compartments or blisters. These can sometimes be useful as a tool to aid self-management of medication. However, they should not routinely be requested by providers where staff are supporting with medication as this is not a personalised approach.
Supporting with Medication from Different Types of Packaging
External link
Medication record requirements in care homes
The manager will ensure that a written record is kept of all medication entering a care home that is being administered to the resident or sent for disposal.
Information must be kept and regularly updated and checked.
Amendments must be made immediately as they occur.
A regular audit of records produced by the care homes is recommended.
The responsible manager must have a written protocol in place which staff are aware of. All staff allowed to administer medicines should be listed by name at the beginning of the MAR sheet folder with a sample signature that they use on the MAR sheet.
A complete record of all medication administered/ not administered must be kept for each service user and for each medicine.
When changes to medication are needed, it is the responsibility of the care provider to keep the MAR sheet up to date.
If the GP issues a new written prescription (which can be issued at any time in the monthly cycle), there should be a new MAR sheet or a new entry written on to an existing MAR sheet. A person may therefore have several MAR sheets, and some may start on different dates.
Verbal orders are not encouraged due to the potential for medication errors. However, in cases where verbal orders are taken, this must be from a qualified prescriber and must be documented by two individual care staff. A new prescription should then follow where appropriate or written confirmation should be sent by secure NHS email within 48 hours of the request being made, signed by the responsible prescriber.
On admission to hospital, the care home must send a copy of the MAR sheet, and other documents in the red bag that accompanies the individual.
For guidance on how to obtain an NHS mail account
NHS mail
External link
Medication is a key part of managing Parkinson’s symptoms and for the person to receive their medication at the right time is important
The Importance of Parkinson’s Medication
The Medicines Safety Team at NHS Leeds ICB has noticed an increase in medication incidents relating to missed doses and delays in the administration of Parkinson’s medication within care settings across Leeds.
Medication to help manage symptoms of Parkinson’s will be prescribed by a clinician for administration at specific times. If people with Parkinson’s don’t receive their medication on time it can seriously impact their health. They may not be able to move, get out of bed, swallow, walk or talk. Some people may never recover and may permanently lose their ability to walk, talk or worse. Even a delay in taking medication of 30 minutes can lead to serious health implications for someone living with Parkinson’s. Please see the British National Formulary (BNF) for the
list of Parkinson’s Medications.
External link
Medication is a key part of managing Parkinson’s symptoms and getting your medication at the right time is important. Parkinson’s UK caught up with a Specialist Parkinson’s Nurse who answers some questions on the topic.
Q&A: the importance of getting Parkinson's medication on time
External link
Parkinson’s UK – Get It On Time Campaign
The Parkinson’s UK Get It On Time campaign calls on all UK hospitals and care homes to ensure every person with Parkinson’s receives their medication on time, every time.
Parkinson’s UK conducted a survey in 2018 of over 700 people affected by the condition to hear about their experiences on medication management. This survey uncovered the huge impact not receiving medication on time can have on people living with Parkinson’s.
- 63% of survey respondents told us they had been admitted to hospital in the last year.
- Only 21% of respondents told us they received their medication on time without having to remind hospital staff.
- 47% were not given the option to administer their own medication, and a further 12% were not always able to do this due to varying practices among health professionals.
- 78% of respondents told us their health got worse as a result of not receiving their medication on time.
Parkinson’s UK has developed a number of resources and support for people living with Parkinson’s and professionals to ensure medication management improves in care settings.
Resources include:
-
The Get It On Time poster
External link – designed to be displayed in clinic rooms to improve staff awareness about how vital timing is for Parkinson’s medication
-
The Get It On Time laminated clock poster
External link – can be placed by the bedside of a person with Parkinson’s to discreetly prompt staff to ensure they get their medication on time
- Get It On Time stickers – can be used to promote our Get It On Time campaign, but can also be used by professionals to add to patient notes and act as a useful reminder to give medicine on time
Get it on time stickers (A4)
External link
Get it on time stickers (A5)
External link
-
The Get It On Time washbag
External link – helps people with Parkinson’s inform staff that they need to take their medication on time. Includes tips on preparing for a hospital stay, a card to record medication, a laminated clock flyer to put by people’s bedsides to prompt staff about their medication, stickers that can be put on notes and a wallet-sized card to help staff understand more about Parkinson’s
-
Medicines optimisation consensus statement
External link – outlines the key medicine management issues people with Parkinson’s face when admitted to hospital and highlights ways to manage these effectively (also includes supporting checklist, case for service change and audit appendices). One key issue is the need to get medication on time.
These resources can all be ordered or printed from
parkinsons.org.uk/GIOTresources
External link In addition to these resources, Parkinson’s UK helpline and local advisers are available to support people living with Parkinson’s and family members on issues around medication management. Call 0808 800 0303 or email
hello@parkinsons.org.uk
Training for care staff
If you'd like the staff in your care setting to understand more about Parkinson's, Parkinson’s UK’s Education team can deliver
an introduction to Parkinson's session for care staff
External link This free 1-hour course will give a solid introduction to Parkinson's for staff in nursing, care homes and home care agencies. At the end of the course, staff will:
- have better knowledge and understanding of Parkinson's
- know the needs of people living with Parkinson's, particularly in a care or nursing home environment
- understand how best to care for people with Parkinson's
- recognise the resources available, including Parkinson's UK, to improve the quality of life of people with Parkinson's and their carers
- have evaluated their own practice and care of people with Parkinson's
Who is the course for?
All staff in nursing and care homes, and domiciliary and home care agencies. If you have any questions, please email
coursebookings@parkinsons.org.uk.
Parkinson’s UK have also produced resources to give care staff more information about Parkinson's.
These include:
You can order printed copies of information by post, phone or email.
https://www.parkinsons.org.uk/information-and-support/ordering-our-resources
Recommendations for Care Staff
- Ensure Care Plans for people living with Parkinson’s is person centred
- Medication Care Plan reflects the instructions from the Specialists Parkinson’s team
- Always record the
actual time the Parkinson’s medication is administered to the individual
- Update PRN (As required) protocols to ensure they are patient centred detailing specific signs and symptoms a person may show when they might require an additional Parkinson’s medication which is prescribed “PRN or as required” For further information please see:
https://www.cqc.org.uk/guidance-providers/adult-social-care/when-required-medicines-adult-social-care
- Ensure robust systems and processes are in place to ensure Parkinson’s medication’s is administered on time: consider the above resources and alarm systems to notify staff
before the medication(s) are due to be administered.
- Where appropriate support residents to administer their own Parkinson’s medication ensuring the role and responsibility of the resident and staff is clear. Complete the appropriate risk assessments and ensure they are regularly reviewed and updated. For further information:
https://www.cqc.org.uk/guidance-providers/adult-social-care/self-administered-medicines-care-homes
- Ensure all staff administering Parkinson’s medication understand the importance of medication for people living with the condition and support further training
- Where alarms have been purchased for staff that remind them to administer their residents Parkinson medication and for homes that have electronic care plans amendments have been made to records to electronically alert staff to administer medication
- Follow internal reporting procedures for the reporting of missed and delayed doses of Parkinson’s medication ensuring advice is sought from an healthcare professional and where appropriate consideration to safeguarding procedures where delays or missed doses has or potentially could cause harm to residents health and wellbeing. (Even a delay in taking medication of 30 minutes can lead to serious health implications for someone living with Parkinson’s)
- Continuous auditing of the administration of Parkinson’s medication
