Clinical SOP 009 Covert Administration Document Control Summary Status: Version: Author/Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures Full Equalities Impact Analysis New v1.1 Date: Dec 15 Mo Azar Policy and Procedures Committee Date: 23 March 17 Policy and Procedures Committee Date: 23 March 17 Medicines Optimisation Strategy 2013-2018: Making the most of medicines February 2016 December 2018 Covert Administration Medicines Code See Medicines Code: Policies and Procedures to Manage the Clinical Risks Associated with the Use of Medicines Contents 1. Introduction... 3 2. Purpose... 3 3. Scope... 3 4. SOP... 3 5. Process For Monitoring Compliance And Effectiveness... 4 6. References... 4 Appendix 1... 5 Appendix 2... 6
Change Control Amendment History Version Dates Amendments V1 Dec 15 V1.1 March 17 Appendix 2 : Checked capacity of patient to consent to treatment
1. Introduction The covert administration of medicines is only likely to be necessary or appropriate in the case of patients or clients who actively refuse medication but who are judged not to have the capacity to understand the consequences of their refusal. 2. Purpose To provide guidance on the use of covert medication. 3. Scope This SOP covers: When the use of covert administration would be appropriate The process of implementing covert administration 4. SOP Disguising Medication in Food The Trust and NMC recognises that there may be certain exceptional circumstances in which covert administration may be considered to prevent a patient/client from missing out on essential treatment. In such circumstances and in the absence of informed consent, the following considerations may apply: The best interests of the patient/client must be considered at all times. The medication must be considered essential for the patients/client s health and wellbeing, or for the safety of others. The decision to administer a medication covertly should not be considered routine, and should be a contingency measure. Any decision to do so must be reached after assessing the care needs of the patient/client individually. It should be patient/client-specific, in order to avoid the ritualised administration of medication in this way. There should be broad and open discussion among the multi-professional clinical team and the supporters of the patient/client, and agreement that this approach is required in the circumstances. Those involved should include carers, relatives, advocates, and the multidisciplinary team (especially the pharmacist). Family involvement in the care process should be positively encouraged. Any pertinent Advance statements must be considered. The method of administration of the medicines should be agreed with the pharmacist, using the most recent and available stability data. The decision and the action taken, including the names of all parties concerned, should be documented in the care plan and reviewed at appropriate intervals.
Regular attempts should be made to encourage the patient/client to take their medication. This might best be achieved by giving regular information, explanation and encouragement, preferably by the team member who has the best rapport with the individual. Please see Appendix 1 Crushing of Medication The crushing of medication is not always covert administration and should not then be viewed in the same way. The decision for the crushing of medication could be made for reasons such as concordance or physical issues by the clinical team in full consultation with the service user. Before any decision is made the pharmacist must be consulted to ensure there will be no pharmacological effect on the medication following crushing, or any specific risks to the staff member from the medicine are identified and can be assessed, and this advice should be documented (see Appendix 1. The prescriber should also be aware, because crushing (unless a crushable formulation) renders each medicine to become unlicensed. The administration of medication to a service user within food or drink should always be subject to a care plan (see sample care plan, Appendix 1). 5. Process For Monitoring Compliance And Effectiveness Audits relating to the use of covert administration. Monitoring of incidents. 6. References Medicines Code
Appendix 1 Covert Administration Introduction This guidance is to be used in conjunction with the NMC code of conduct. The NMC Position Statement on Covert Administration 2007 was used to produce this document and should be read prior to assessing any patient where covert administration is being considered. The NMC recognises that there may be certain exceptional circumstances where covert administration may be considered to prevent a client missing out on essential treatment. In such circumstances, and in the absence of informed consent, the following considerations apply. The best interests of the client must be considered at all times The medication must be considered essential for the client s health and well-being, or for the safety of others The decision to administer covertly should not be considered routine, and should be a contingency measure. Any decision to do so must be reached after assessing the client s needs individually and must be client specific There should be full discussion among the multi-disciplinary team and supporters of the client, and agreement that this approach is required in the circumstances The method of administration should be agreed with the pharmacist The decision and action taken must be documented in the care plan, see the attached forms Regular attempts should be made to encourage the client to take their medication NB covert administration to patients detained under the Mental Health Act and who have capacity is not covered by this policy. If such a situation should arise the responsible Team should raise the matter with the Medical Director and take legal advice
Appendix 2 - Form A Patient name.number Covert Administration Checklist To be completed by Care Co-ordinator Action Tick when complete Checked capacity of patient to consent to treatment Prescriber has approved the use of covert administration Prescriber has assessed the necessity for current medication Carers have been consulted and agreed to the use of covert medication There are no current & pertinent Advance statements or a living will Pharmacist has reviewed medication Signature Date.. Review date..
Appendix 2 - Form B Patient name Number. Medical Review of Medication To be completed by prescriber Medication Risk if refused ///////////////////// Life Significant No significant threatening deterioration deterioration Signature Date..
Appendix 2 - Form C Patient name.number MDT Consensus Agreement to use of Covert Administration Client. The named client is refusing to take their prescribed medication and is unable to fully understand the consequences of this. In the opinion of the following members of the care team, and with the agreement of their carers, it is in their best interests to be given their medication disguised in food or drink to prevent deterioration to their health. Prescriber Main carer Named nurse/care co-ordinator Unit manager Pharmacist Signed. Date.
Appendix 2 - Form D Please ring the reason for the medication assessment below Medication Assessment for: Covert Administration Crushing and/ or Administration in Food/Drink To be completed by a pharmacist Patient name NHS Number.. NB medication must not be crushed unless there is no alternative; doing so makes the medication unlicensed Prescribed medication Liquid available May be crushed Food or drink Reference Alternative Y/N Y/N vehicle if crushed preparation Pharmacist Name:..Signed.. Date..
Sample Care Plan for Disguising Medication in Food and Drink (Covert administration) Client..needs to take the medication detailed in the assessment to maintain their health and well-being in a safe and appropriate manner. Action plan This patient will be given the opportunity to take their medication voluntarily. If they refuse medication that is considered essential for their health and well-being, it will be disguised in food or drink as specified by the pharmacist and documented in their notes If they refuse the disguised medication, it must be discarded, and the refusal recorded on the administration record on the prescription card, and in the care record by the nurse. If the food or drink is being administered by another member of staff as a delegated duty, the nurse has to supervise and remains responsible for the administration of the medicine (including recording) If they only partly take the disguised medication, then an estimate must be made of the dose taken, and this recorded on the administration record on the prescription card, and in the care record Inform the prescriber if the dose has not been administered as prescribed Signature.. Date..
Sample Care Plan for Administering Medication in Food and Drink (NOT Covert administration) Client..needs to take the medication detailed in the assessment to maintain their health and well-being in a safe and appropriate manner. Action plan This patient has agreed to have his/her medication administered in food/ drink because of the following rationale. (e.g. swallowing difficulties) If they are unable to take medication that is considered essential for their health and well-being, it will be administered in food or drink as specified by the pharmacist and documented in their notes If they refuse the medication administered in the food/drink, it must be discarded, and the refusal recorded on the administration record on the prescription card, and in the care record by the nurse. If the food or drink is being administered by another member of staff as a delegated duty, the nurse has to supervise and remains responsible for the administration of the medicine (including recording) If they only partly take the medication, administered in the food/drink. then an estimate must be made of the dose taken, and this recorded on the administration record on the prescription card, and in the care record Inform the prescriber if the dose has not been administered as prescribed Signature.. Date..