The purpose of this sample self-administration of medication policy is to help your organization define its medication administration practices in a way that safely facilitates access to self-infusions and self-injections. Please use the language from this document that is relevant to your institution and make any changes that are appropriate for your organization. This is a sample document for informational purposes only and does not need to be fully incorporated.

All patients* will be assessed by a qualified staff member for risk and readiness to participate in the self-administration of medication program in conjunction with and/or upon approval from their [bleeding disorder treatment team or other medical provider] team. 

• Any patient assessed as capable of safely and effectively participating in the self-administration of medication program will receive education about the facility’s self-administration policies, including the policies related to observation. 

• Patients assessed as too high-risk or incapable of safe self-administration shall remain on the staff-administered medication program.

  • The staff-administration of medication program may include administration of medication by members of the staff, contracted providers, or other trained individuals (through a single use case agreement or a family member). 

  • Ongoing assessments of the patient's ability to safely and effectively self-administer medication will be performed by a qualified member of staff, and regular determinations will be made as to level of the program in which the patient will participate: partial self-administration, full self-administration, or staff-administration. 

*While we recognize that mental health and substance use treatment programs use a range of terms to describe the people who they are serving such as “patient,” “client,” recipient,” “guest,” etc. In order to maintain consistency of terminology, this document will use the term “patient.” As with all of the pieces of this document, please change the language to meet the needs of your individual program.

• A qualified member of staff will complete a risk assessment and a readiness assessment on the selected patient to determine the capability of safe self-administration of their medications in conjunction with and/or upon approval from their [bleeding disorder treatment team or other medical provider] team. 

• Patients determined to be capable of safe self-administration of medications will be assigned a participation level. 

  • Partial self-administration of medication: The patient administers his/her medication at the prescribed times while supervised by staff. The patient will present to the medication office with or without prompting by staff to request their scheduled medications at the appropriate time. Medications will remain locked in the medication room until the prescribed time for administration. Staff will watch as the patient prepares their own medication from their supply and administers the medication (including infusing or injecting) themselves. Self-administration observation will be documented in the patient's [the medication administration record or the section of the medical record related to administration of medication]. 

  • Full self-administration of medication: Participation in the full self-administration of medication program offers greater independence of medication handling, storage, set up and administration. The patient will store medications in a lock box or refrigerator based on medication specifications. Staff will monitor the patient’s medication compliance by checking in with the patient and observing the storage space. These checks will be documented in the [the medication administration record or the section of the medical record related to administration of medication]  

    • Staff will conduct ongoing assessments of the patient’s continued ability to participate in the self-administration of medications program, as described in the Ongoing Assessments section below. 

• Orientation to Self Administration 

  • Qualified staff will conduct an orientation with the patient of the self-administration program by reviewing the orientation sheet, including: 

    • where medications and supplies will be kept

    • when administration will be completed 

    • location for administration (ie. private office, medication office)

    • who will observe

    • where used supplies, including sharps, will be disposed of

    • how medication administration will be logged and recorded

  • The patient may decline or accept participation in the Self- Administration program at the completion of the orientation. 

• Ongoing Assessments 

  • Ongoing assessments of the patient's ability to safely and effectively self-administer medication will be performed by a qualified member of staff, and regular determinations will be made as to level of the program in which the patient will participate: partial self-administration, full self-administration, or staff-administration. The qualified member of staff who conducted the assessment will document the appropriate level of medication administration in the patient’s [the medication administration record or the section of the medical record related to administration of medication].  

    • For example, in the event staff notes that the recipient's lock box isn’t locked, medications are left unattended, sharps have not been properly disposed, or medications have not been taken appropriately, the patient should be assigned to the staff-administered medication program.

• Safety

  • All staff will be trained via the Medication Self-Administration Policy and Procedure prior to independently carrying out this procedure.

  • If at any time the patient is found at risk and/or is unable to safely and effectively self-administer their medications, the patient will return to staff-administered status, and future risk and readiness assessments will take place on an ongoing basis to see if the patient may return to self-administration.