• TS: – Self-Administration of Medications: Complying with MM.06.01.03 [REF: MDx, P&T, PtAd/Ed, Phrm, RN] The Source, December 2012, Vol 10, #12, Pg 8  [®]

If your organization permits self-administration of medication by patients, this article is a useful review of the basic requirements of both CMS and TJC as found in MM.06.01.03.  Given the obvious safety concerns, this is a standard that requires careful attention to the details of compliance and written proof of the same.  The key points are in the need for:

• Written guidelines and polices developed by a multidisciplinary group (that included MD,nursing and pharmacy)
  
• Specific determination about which patients and what medications would be approved for self-administration
  
• A plan for safe storage of such medication
  
• An approach for determining patient appropriateness and competence for self-medication that is properly grounded in and supported by patient (and family if needed) education.  

The article focuses largely on the education component making it clear that it should at minimum include information about :

• The medication; its effects and side effects  and,
  
• How to properly/safely administer the medications
  

To this end the article recommends a ‘teach-back’ approach that confirms what the patient has learned by having them teach back what they have learned to their instructor.  Whether in a notebook or standardized form, there is also an emphasis on the importance and requirement for effectively documenting all medication that is self-administered and the need for both patients and staff to be trained for this.

TIP: Have P&T review any policies related to medication self-administration and include self-administering patients in your next mock tracers.