Use of patients own drugs

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Patients are encouraged to bring their medicines into hospital with them to aid the medicines reconciliation process.

Sometimes however they may be prescribed something that pharmacy do not stock or that the wards cannot easily access out of hours.

This procedure describes processes ward staff should follow to assess patients own medicines as fit for use.

Patient's own drugs remain their property and consent must be obtained to use or destroy them.

Use the POM1 form to record the receipt and if applicable destruction of patient's own drugs.

Procedure - medicines dispensed normally
  1. The patient must consent to the use of their medicines.
  2. Only medicines that can be positively identified can be used.
  3. Check when the medicine was dispensed and do not use it if that was more than 3 months ago or if the expiry date has been exceeded. Eye preparations must have been in use for less than 4 weeks. If the eyes are infected, fresh supplies must be obtained.
  4. The medicine must be correctly and fully labelled meeting all legal requirements (see full procedure).
  5. Containers must hold only one type or brand of preparation from the same supply.
  6. Tablets and capsules may only be used if they are foil packed or loose in their original container.
  7. The member of staff assessing the general condition of the product, it's packaging and labelling must be satisfied of its suitability. Patient safety is paramount.
  8. Patient's own drugs must only be used for the patient named on the label.
  9. Use the assessment checklist.
  10. Medicines must never be used in the following circumstances:
    • More than one type of drug is in the container
    • Special storage requirements apply
    • Loose tablets or capsules outwith the original container
    • Foil strips not in labelled container
    • Short shelf life once opened
    • No label present
    • Opened jars, tubs or tubes of creams, ointments or lotions
    • Expired or were dispensed more than 3 months ago
Procedure - medicines dispensed in a compliance device

Please note this deviation from the NHS GG&C Safe & Secure Handling if Medicines Policy has been approved by Mental Health Prescribing Management Group.

This procedure applies to mental health and learning disability in-patient wards only.

Patient's compliance devices brought into hospital may only be in used if the following criteria are met:

  • Only sealed disposable compliance devices may be considered for use.
  • The compliance device must have been prepared within the last 6 weeks.
  • The device must be fully labelled or have information attached to it identifying the patient and the contents.
  • Count the tablets or capsules contained in the device to ensure the quantities correspond with the labels.
  • The in-patient prescription sheet corresponds exactly with the details on the labels.
  • No medicine in the compliance device is to be withheld, changed or discontinued.
  • Use all the medicines in the device until such time as stock is obtained from pharmacy. If the in patient prescription contains additional medicines not contained in the device administer those from ward stock.
  • If in doubt contact pharmacy for advice.
  • The patient must consent to the use of their compliance device.
  • Use the assessment checklist.


Editorial Information

Last reviewed: 29 August 2019

Next review: 01 April 2022

Author(s): PMG-MH

Version: 1

Approved By: Mental Health Prescribing Management Group

Reviewer Name(s): Lead Clinical Pharmacist, Clinical Effectiveness Pharmacist