NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section.

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1 TITLE MANAGEMENT OF PATIENT S OWN MEDICATIONS SCOPE Prvincial APPROVAL AUTHORITY Clinical Operatins Executive Cmmittee SPONSOR Prvincial Medicatin Management Cmmittee PARENT DOCUMENT TITLE, TYPE AND NUMBER Nt applicable DOCUMENT # PS-98 INITIAL EFFECTIVE DATE Octber 1, 2018 REVISION EFFECTIVE DATE Nt applicable SCHEDULED REVIEW DATE Octber 1, 2021 NOTE: The first appearance f terms in bld in the bdy f this dcument (except titles) are defined terms please refer t the Definitins sectin. If yu have any questins r cmments regarding the infrmatin in this dcument, please cntact the Plicy & Frms Department at plicy@ahs.ca. The Plicy & Frms website is the fficial surce f current apprved plicies, prcedures, directives, standards, prtcls and guidelines. OBJECTIVES T establish a safe and cnsistent apprach fr managing patient's wn medicatins in Alberta Health Services (AHS) settings. PRINCIPLES Medicatins supplied by AHS shuld be used whenever pssible. The use f patient s wn medicatins shuld be limited. AHS is cmmitted t ptimizing safe patient care in AHS settings by: ensuring that patient s wn medicatins are nly administered t patients when it is safe and necessary t d s; ensuring that patient s wn medicatins are safely and apprpriately stred, dcumented, and transprted, and returned t the crrect patient r dispsed f per Zne/prgram/site prcesses; and invlving patients as partners in their care. An rder frm an authrized prescriber is required fr the use f patient s wn medicatins in an AHS setting (refer t the AHS Medicatin Orders Plicy and prcedures). APPLICABILITY Cmpliance with this dcument is required by all Alberta Health Services emplyees, members f the medical and midwifery staffs, Students, Vlunteers, and ther persns acting n behalf f Alberta Health Services (including cntracted service prviders as necessary). Alberta Health Services (AHS) PAGE: 1 OF 5

2 ELEMENTS 1. When This Plicy Des Nt Apply 1.1 This plicy des nt apply t patient's wn medicatins in the fllwing settings: a) Hme Care (including Hme Care ambulatry clinics); b) Supprtive Living; c) Respite Care; d) Restrative Care; and e) Crrectins. 1.2 This plicy des nt apply t any self-administratin f medicatins by the patient, including self-administratin f patient s wn medicatins and selfadministratin f medicatins prvided by the site s designated pharmacy. 1.3 This plicy des nt apply t the management f cannabis fr medical purpses. 1.4 This plicy des nt apply t substances and medicatins that are nt legal fr sale r use in Canada. a) If an illegal substance is discvered during the patient's wn medicatins verificatin prcess, the site's plicy/prcedure/prcess fr management f illegal substances shall be fllwed. 2. When This Plicy Applies 2.1 This plicy shall apply t patient s wn medicatins that are nt prvided by the site s designated pharmacy, if there is ne, and included within at least ne f the fllwing categries: a) prescriptin medicatins (including narctic and cntrlled substances); b) ver-the-cunter (OTC) medicatins; c) Special Access medicatins authrized by Health Canada; d) clinical trial medicatins (including investigatinal medicatins); e) cmpunded preparatins; f) medicatins frm ther cuntries (if legal in Canada r imprted fr persnal use under Health Canada s Imprt and Exprt Plicy fr Health Prducts Under the Fd and Drugs Act and its Regulatins, and can be verified); g) natural health prducts; Alberta Health Services (AHS) PAGE: 2 OF 5

3 h) specific brands f medicatins and medicinal prducts nt stcked by the site s designated pharmacy; and i) sample medicatins prvided by an authrized prescriber r clinic. 2.2 The use f patient's wn medicatins in AHS settings is nly authrized when at least ne f the fllwing applies: a) the prescribed medicatin cannt be supplied by the site s designated pharmacy, if there is ne; b) the prescribed medicatin is nn-frmulary n the applicable drug frmulary fr the practice setting; c) there is n suitable frmulary alternative available; d) the authrized prescriber des nt want the patient t receive the frmulary alternative; e) the prescribed medicatin is n frmulary but its use is restricted fr a different indicatin; f) the patient and/r alternate decisin-maker requests t use the patient s wn medicatin supply and the authrized prescriber agrees; r g) the prgram requires the use f patient s wn medicatins. 2.3 After the medicatin recnciliatin prcess is cmpleted (as per the AHS Medicatin Recnciliatin Plicy), the patient's wn medicatins nt rdered fr use while the patient is in care, shall be given t the patient's family fr safe and secure remval frm the premises, when pssible. Fr ambulatry care visits, patients / patients' family shuld take their wn medicatins hme after the visit r cmpletin f treatment. a) If the patient s wn medicatins cannt be remved frm the AHS setting, these medicatins shall be placed in safekeeping and transprted safely and securely per the AHS Management f Patient's Own Medicatins Prcedure. b) Patient's wn medicatins that are held in safekeeping r stred by AHS, shall be returned t the patient and/r family at the end f treatment r at transfer per the AHS Management f Patient's Own Medicatins Prcedure. 2.4 When a patient s wn medicatin is t be used, all dcumentatin, verificatin, and strage requirements shuld ccur at the initial pint f entry fr care (e.g., inpatient admissin, utpatient clinic visit) within AHS. 2.5 Agreement by the patient r alternate decisin-maker is required t use the patient's wn medicatins in accrdance with the AHS Cnsent t Alberta Health Services (AHS) PAGE: 3 OF 5

4 DEFINITIONS Treatment/Prcedure(s) Plicy and prcedures. The health care prfessinal shall dcument this agreement in the patient's health recrd, in a place designated by the Zne/prgram/site. 2.6 Prir t a health care prfessinal administering a patient's wn medicatin, the patient's wn medicatin shall be crrectly identified and verified as safe t administer by a Pharmacist r Pharmacy Technician, r by anther health care prfessinal if a Pharmacist r Pharmacy Technician is nt available. (See the AHS Management f Patient's Own Medicatins Prcedure.) 2.7 The management and use f patient's wn medicatins, including strage, shall be dcumented per the AHS Management f Patient's Own Medicatins Prcedure. Alberta Health Services (AHS) settings means any envirnment where treatment/prcedures and ther health services are delivered by, n behalf f r in cnjunctin with, Alberta Health Services. Alternate decisin-maker means a persn wh is authrized t make decisins with r n behalf f the patient. These may include, specific decisin-maker, a minr s legal representative, a guardian, a nearest relative in accrdance with the Mental Health Act (Alberta), an agent in accrdance with a Persnal Directive, r a persn designated in accrdance with the Human Tissue and Organ Dnatin Act (Alberta). Authrized prescriber means a health care prfessinal wh is permitted by Federal and Prvincial legislatin, their regulatry Cllege, Alberta Health Services and practice setting (where applicable) t prescribe medicatins. Family(-ies) means ne r mre individuals identified by the patient as an imprtant supprt, and wh the patient wishes t be included in any encunters with the health care system, including, but nt limited t, family members, legal guardians, friends and infrmal caregivers. Health care prfessinal means an individual wh is a member f a regulated health discipline, as defined by the Health Disciplines Act (Alberta) r the Health Prfessins Act (Alberta), and wh practises within scpe and rle. Health recrd means the Alberta Health Services legal recrd f the patient s diagnstic, treatment and care infrmatin. Natural health prducts mean medicinal prducts cntaining herbs, vitamins, minerals, and nutritinal supplements (als knwn as traditinal, natural, hlistic r hmepathic medicines). Over-the-cunter (OTC) medicatins means medicatins that can be btained withut a prescriptin, per the Pharmacy and Drug Act (Alberta) and as aligned with the natinal drug schedule identified by the Natinal Assciatin f Pharmacy Regulatry Authrities (NAPRA). Alberta Health Services (AHS) PAGE: 4 OF 5

5 Patient means an adult r child wh receives r has requested health care r services frm Alberta Health Services and its health care prviders r individuals authrized t act n behalf f Alberta Health Services. This term is inclusive f residents, clients and utpatients. Patient s wn medicatins means the medicatins that a patient has with them at presentatin r admissin t a health care facility, prgram r service, r that are brught in frm an external surce at a later time. REFERENCES Alberta Health Services Gvernance Dcuments: Management f Patient's Own Medicatins Prcedure (PS-98-01) Medicatin Orders Plicy and Prcedures (#PS-93) Medicatin Recnciliatin Plicy (#PS-05) Nn-Alberta Health Services Dcuments: Imprt and Exprt Plicy fr Health Prducts Under the Fd and Drugs Act and its Regulatins (Health Canada) VERSION HISTORY Date Click here t enter a date Click here t enter a date Actin Taken Optinal: Chse an item Optinal: Chse an item Alberta Health Services (AHS) PAGE: 5 OF 5