Medication Management Policy
| Policy area | Medication Management |
| Document type | Policy |
| Applicable to | Beyondlimits Care & Support Services |
| Version | 001 |
| Date approved | 19/08/2024 |
| Approved by | Managing Director |
| Next review date | Every 12 Months |
| Related policies | Client Health and Wellbeing Policy Incident Management Policy Risk Management Policy Client Feedback and Complaints Management Policy Emergency and Disaster Management Policy Transition of Care Between Different Environments Policy Client Living Alone and Receiving Personal Care from Sole Worker Policy Duty of Care Policy Client Advocacy Policy Consent Policy Diversity Policy Service Delivery Policy Service Access and Exit Policy Privacy Policy Work Health and Safety Policy Human Resources Management Policy Information Management Policy |
| Authority | NDIS Act 2013 NDIS Practice Standards and Quality Indicators NDIS Code of Conduct Aged Care Act 1997 Aged Care Quality and Safety Standards Aged Care Code of Conduct Privacy Act 1988 |
PURPOSE
The purpose of this policy is to explain our organisation’s commitment and approach to medication management.
SCOPE
This policy applies to all our workers (employees, contractors and volunteers) who support clients with medication management requirements.
DEFINITIONS
| Term | Definition |
|---|---|
| Antimicrobial Agents/Antimicrobial Resistance | These are medications used to treat and prevent infections. They include antibiotics, antivirals, antifungals and antiparasitics. If antimicrobial agents are misused or overused, the microbes that cause infection can become resistant to them (antimicrobial resistance), causing infection to linger with negative impacts on the client’s health and wellbeing. |
| Chemical Restraint | The use of medication for the primary purpose of controlling a client’s behaviour, which may otherwise cause harm to themselves or others. This is a regulated restrictive practice and there are strict rules on how and when this should be used. See below ‘psychotropic medications’. |
| Cytotoxic Medications | A substance that kills cells, including cancer cells. For example, chemotherapy and radiotherapy. |
| Home Medicines Review | A collaborative medication review for people in the community. A referral from a GP is required and an accredited pharmacist interviews the client or family/alternate decision-maker/advocate and workers, reviews their medications and then provides a report to the client’s GP. It is fully funded by Medicare and available every 24 months to any person at risk of or experiencing medicationrelated adverse effects, or there is an identified clinical need. |
| Medication Support | This involves: ● reminding or prompting a client to take their medication; ● assisting with opening medication containers; and ● providing other assistance, which does not include use of a medication aid. |
| Medication Assistance | This involves: ● storing medicines; ● opening medicine containers; ● removing the prescribed dosage (from an approved container, such as a Webster Pack); and ● giving the medicine to the client in accordance with instructions on the pharmacy label. |
| Polypharmacy | The use of five or more medications, or two or more psychotropic medications, at the same time, to treat one condition or multiple conditions. It includes the use of all prescription, over-the-counter and complementary medications. |
| Pro Re Nata (PRN) Medications | Medications taken or used ‘as needed’ — either over a long or short-term period. It is taken or used in response to specific conditions or symptoms |
| Psychotropic Medications | Medication capable of affecting the mind, emotions and behaviour. They include (antidepressants/antianxiety, anticonvulsants, stimulants and opioids. |
| Schedule 8 Medications | These are ‘controlled drugs’ under the Therapeutic Goods Administration that must meet specific conditions when being produced, supplied, distributed, owned and used. They are classified as drugs of dependence. While they offer significant therapeutic benefits, they also have a high risk of misuse, abuse and dependence. |
CONTEXT
Our organisation is committed to providing safe and quality care and support to our clients. We will implement and maintain a medication management approach that:
- is strictly within our scope of practice;
- follows directives and best practice recommendations from a qualified health practitioner as required;
- focuses on the safe and careful use of medications;
- does not constitute unauthorised restrictive practice (chemical restraint);
- encourages independence and capacity-building so clients can self-manage all, or some of their own medication(s) where possible;
- escalates health and medication-related risks, incidents and concerns promptly;
- upholds client privacy and dignity; and
- facilitates information-sharing with relevant stakeholders to optimise client outcomes.
POLICY STATEMENT
#1
Compliance with Health Practitioner Directives
- We will follow the 12 Guiding Principles for Medication Management in the Community (Department of Health and Aged Care, 2022 edition).
- We will administer client medications strictly in accordance with directions from a qualified health practitioner
- We will proactively prevent or minimise antimicrobial resistance by administering, or supporting clients to self-administer, prescribed antimicrobial agents strictly in accordance with the health practitioner’s instructions, and for longer than is required/prescribed.
#2
Consent
- We will encourage and support clients to be involved in their own medication management decision-making, where possible.
- We will obtain written consent from the client or family/alternate decision-maker/advocate before we administer client medication and before sharing medication information with other stakeholders.
- We will ensure the client is aware that they can change or withdraw their consent at any time and support them to do so if requested.
#3
Safe and Quality use of Medicines
- We will maintain processes to support the client’s safe and quality use of medicines, including to:
- maintain a current and accurate record of all medicines, with clinical reasons for the treatment (including for PRN medications) and the details of the prescribing practitioner.
- ensure workers and others providing care to the client have access to the client’s up to date medicine list and other supporting information at transitions of care (going to hospital, hospice, short-term accommodation, residential care);
- ensure medicine-related information is available to the client and relevant workers;
- ensure safe medicine administration, including assessing the client’s swallowing ability, providing alternative safe formulations (e.g. crushing medication) when required and as directed by a qualified health practitioner;
- minimise interruptions and assisting with timely access to medicines (client is prescribed a new medicine, change to medicine directed by a qualified health practitioner);
- where required, assist with remote access for prescribed medicine; and
- identify, monitor and mitigate risks to clients taking high-risk medicines, including reducing the inappropriate use of psychotropic medicines.
#4
Medication Errors, Omissions and Incidents
- We will maintain processes to minimise the risk of medication errors, omissions and incidents.
- We will take appropriate action(s) as required to ensure the health, safety and wellbeing of the client in the event there is a medication error, omission and incident.
- We will conduct internal and external reporting of medication errors, omissions and incidents in accordance with required timeframes and formats.
- We will document medication errors, omissions and incidents in the client file and other client documents (e.g. Support Plan) as required.
- We will document medication errors, omissions and incidents in the Incident Register to identify trends, gaps and areas for improvement and take remedial action(s) as required (changes to worker rostering, improved communication, training and supervision, revision of policies and procedures).
- We will contact the client’s health practitioner and/or family/alternate decisionmaker/advocate if the client chooses not to take their medication, or if they miss a dose and/or if they no longer have capacity to self-manage their medication. Note: We will obtain the client’s written consent to do this.
#5
Medication Storage and Disposal
- We will store medications safely and securely and in accordance with the manufacturer’s instructions and best practice guidelines (in the fridge, at room temperature).
- We will store medications in a way that safeguards clients and also others who live, work or visit the home (including children and pets).
- We will ensure medications are stored separately to antiseptics, disinfectants and other chemicals.
- In a supported accommodation (SIL, STA or SDA) setting, we will:
- store Schedule 8 drugs in a lockable room and/or in a steel lockable storage facility fixed to the floor or wall;
- ensure medications can only be accessed by people authorised to access them;
- uphold the client’s privacy and dignity in terms of discretion and confidentiality; and
- clearly label clients’ medications so they can be distinguished from other residents’ medications.
- We will return to the pharmacy medications in their original packaging or in a dose administration aid (Webster pack) that are expired, or no longer being administered to, or taken by the client.
#6
Transition of Care Between Different Environments
- We will communicate and share information as required with other service providers, (with the client’s or family/alternate decision-maker/advocate’s consent) to ensure the client continues to receive their prescribed medications if they are transitioning in or out of our services.
#7
Assessments, Monitoring and Review
- We will conduct client risk assessments at intake, during reviews and service provision and escalate any health and medication-related issues, risks or concerns.
- We will communicate and collaborate with qualified health practitioners as required
- We will maintain a process to ensure medication reviews by a qualified health practitioner are conducted:
- at intake;
- when there is a transition of care between different environments;
- annually when care is ongoing;
- when there is a change in diagnosis or an observed deterioration in behaviour, cognitive or physical function, capacity or condition;
- when there is polypharmacy (multiple medications) and the potential to reduce the number of medications;
- when a new medicine is started, or there is a change to an existing medicine or the medication management plan; and/or
- when there has been an incident or adverse event that is potentially related to medicines.
- We will ensure a qualified health practitioner reviews, plans and makes changes to medicines for the client, when the client is acutely unwell.
- We will organise a Home Medicines Review to eligible clients, every two years.
- We will regularly review and improve the effectiveness of our system and processes for the safe and quality use of medicines.
#8
Information and Record-keeping
- We will ensure information and records are accurate and up to date.
- We will document existing or known allergies or side effects to medicines, vaccines or other substances at intake/commencement of services and monitor and update documentation when new allergies or side effects occur.
- We will ensure the client has provided us with all required written consents.
- We will store the information securely to ensure privacy, dignity and confidentiality and make sure it is accessible to the client and only other stakeholders authorised to access it
#9
Worker Training and Supervision
- We will maintain a skilled and trained workforce, which has required medication management training in the purpose of medication, medication effects and side-effects and how to respond to and escalate medication incidents.
- We will maintain processes to adequately monitor and supervise workers.
SUPPORTING DOCUMENTS
Related procedures and forms include:
- Medication Administration Chart
- Annual Medication Administration Competency Assessment Template
- Authority to Act as an Advocate Form
- Code of Conduct Agreement
- Doctor’s Medication Order Form
- Drug Register for Controlled Drugs
- Client Feedback and Complaints Management Procedure
- Complaints and Feedback Form
- Incident Repor
- Incident Investigation Form
- Incident Register
- Medication Incident Form
- Self-Administration of Medication Assessment
- Medication Plan and Consent Form
- PRN Care Plan
- PRN Intake Checklist
- PRN Protocols
- Privacy and Confidentiality Agreement
- Medication Management Procedure
- Medication Management - Difficulty Swallowing Procedure
- Infection Management Procedure
- Pain Management Procedure
- Polypharmacy Procedure
- Respiratory Depression Medication Procedure
- Cardiovascular Management Procedure
- Epilepsy Management Procedure
- Reportable Incident Management Procedure
- Incident Management Procedure
- Risk Assessment Form
- Risk Indemnity Form
- Risk Management Plan Register
- Risk Management Policy and Procedure
RESPONSIBILITIES
Managing Director is responsible for:
- maintaining this policy, its related procedures and associated documents;
- ensuring the policy is effectively implemented across the service;
- monitoring workers compliance with the requirements of this policy; and
- ensuring training and information is provided to workers to carry out this policy.
All workers are responsible for complying with the requirements of this policy.
COMPLIANCE
Deliberate breaches of this policy will be dealt with under our misconduct provisions, as stated in the Code of Conduct Agreement.
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