Right Participant Right medication Right dose Right time Right route

Policy Consultation and review

This policy is under review and is seeking your consultation.  Please read and review the document and provide comments at the bottom.  Your comments will be acknowledged by the Policy committee and will be taken into review for any further changes.


Policy Number:   3.B.3

Effective From:  9 February 2018

1. AIM


To give clear guidelines to FLINTWOOD employees to administer and store Participant medication whilst at FLINTWOOD service.




This policy applies to all employees responsible for the administration and storage of Participant medication.




Basic terminology:

b.d twice a day

NBM nil by mouth

g grams

p.r.n when necessary

L litres

q.i.d four times a day

mane in the morning

stat administer at once

mcg micrograms

SR slow release

mg milligrams

t.d.s three times a day

ml millilitres

UTI urinary tract infection

nocte at night

URTI upper respitory tract infection


Assistance to access community, social and recreational activities:  

the opportunity for people with disability/s to participate in their community and enjoy a range of purposeful, recreational and leisure activities. In NSW, community, social and recreational activities are generally provided by nongovernment organisations such as FLINTWOOD who are funded by NDIS.



is a substance that is taken into or placed on the body to achieve one of the following:

  • Cure
  • Treat
  • Relieve or prevent illness


Regular Medication:

  • Prescribed for chronic, long term or specific conditions and are taken on a regular basis. They may be taken daily or several times a day.
  • Can be prescribed for a long or short time (e.g. anitbiotics)

regular medication


Pro Re Nata – PRN Medication:

  • Prescribed to be taken as required or as necessary by the

Pro Re Nata – PRN Medication


Brand Name:

  • given to a medication by the company who manufactures the medication.
  • The name is usually written in larger letters


Generic Name:

  • Is the active ingredient in the medication. This is usually written in smaller letters under the brand name.



a person in receipt of services from FLINTWOOD


Person Responsible: 

The ‘person responsible’ as stated in the Guardianship and Administration Act 1995 creates a system whereby a person whose disability impairs their ability to make decisions for themselves regarding medical or dental treatment may have that decision made on their behalf by a person outside the treating team who will consider the best interests of the person with a disability.


Pharmacy Label:

supplied by the pharmacy at the time of purchase of medication for the purposes of ensuring the right medication and right dosage is given to the right Participant at the right time.

Residential Service/supported Accommodation:

different accommodation types and service models that are designed to support people with disability across the spectrum, ranging from low support needs through to 24 hours a day support.


Short Term Accommodation (STA):

Short Term Accommodation (STA), previously known as ‘Respite’ is a service which provides the person with disability with planned, short – term, time – limited breaks from their current home environment. They are services that assume the caring role during the period of STA with the intention that families/carers resume care at the end of the STA.


Webster Pak:

also known as a blister pack will contain a Participant’s medication for the duration of their time spent in FLINTWOOD’s service. All information on the Webster Pak or pharmacy label must correspond with information on the Medication Management Form.

Webster Pak



4.1  FLINTWOOD recognises the rights of Participants to be actively encouraged and supported to manage and administer (where possible) their own medication.


4.2  FLINTWOOD recognises the rights of the Participant to consent to the medications they are to use.


4.3  FLINTWOOD respects the rights of Participants to be provided with up to date and accurate information on the known risks and benefits of medications. This information is presented in ways that meet the Participants personal needs and comprehension level by the prescribing doctor.


4.4   FLINTWOOD is committed to ensuring that upon informed consent being attained, medication is stored and administered safely.


4.5  All medications are administered by employees or by the individual Participant (if they self-administer). Non-prescription medications are administered in accordance with the manufacturer’s instructions.


4.6  Support workers have a duty of care to ensure medication is used safely and appropriately. An employee must take reasonable care that his /her acts or omissions do not adversely affect the health and safety of the Participants we support and other employees. This is achieved by:

  • Ensuring safety and proper use of medications by the Participants
  • Storing medications in a safe and secure place
  • Maintaining accurate documentation
  • Prompt and app

alcohol and supplements (over the counter) have the potential to interact with prescribed medication by enhancing the effects, increasing side effects and slowing elimination of medication. It is important for Participants to check with their doctor before consuming alcohol or supplements.

Medication Plan


4.7   All Participants who access FLINTWOOD and use any form of regular / routine medication (prescription or non-prescription) must have a Medication Management Form (MMF) completed by an authorising Medical Professional (GP, Dentist or other Medical Specialist) before accessing FLINTWOOD services.

Medication Management Form


4.8  Medication Management Form (MMF) must include:

  • Clear photo of person we support that matches photo on Webster Pak – photo to be supplied by Participant/Carer and placed on Webster Pak by employee/s.
  • Person’s name and date of birth
  • Allergies
  • Medication name
  • Time to be given
  • Route
  • Dose
  • Prescriber’s name, signature and date


4.9  An MMF is to be maintained for all Participant’s taking medications, regardless of whether the medication is taken whilst at a FLINTWOOD or not.


4.10  Regular, PRN and over the counter medications must be recorded by the doctor on the MMF in order for staff to administer.

Accepting Medication into FLINTWOOD


4.11  All medication including, regular, prn and over the counter medication can only be prescribed by a doctor, specialist, dentist or nurse practitioner.


4.12  The medical practitioner reviews the Participant and decides on appropriate medication(s).


4.13  The medical practitioner writes a prescription and completes a Medication Management Form (MMF).


4.14  Doctor’s order in Letter format (eg after discharge from hospital), can be accepted for 72 hrs then a new MMF must be completed.


4.15   The prescription is to be taken to the pharmacist who dispenses the medication


4.16  All prescribed / routine medications will only be accepted into FLINTWOOD services in a Webster Pak or its originally dispensed packaging (if not practicable for a Webster Pak). These include the following:

  • liquid
  • syrup
  • granules
  • powders
  • creams / ointments
  • nasal sprays
  • nebulisers / inhalers


4.17 All medications must be clearly labelled and include the following:

  • Participants full name
  • DOB
  • Identifying picture (service responsibility)
  • Drug name
  • Time / s
  • Frequency
  • Route medication is to be administered
  • Any known allergies
  • Prescribing Doctor’s name
  • Contact number
  • Pharmacy contact details (where packaged)
  • Expiry date


4.18 All alternate type medications, vitamin supplements, herbal remedies will be deemed medications and be subject to the same requirements as regular and / or PRN medications.

Crushing Medication


4.19 Not all medications are safe to crush prior to administration


4.20 Crushing medication can change the absorption characteristics or stability. Medication can become toxic or the efficiency can be decreased.


4.21 Special coatings (enteric) may protect the tablet from light, disguise the taste or ensure the product is released into the body beyond the stomach.


4.22 Enteric coatings ensure controlled release of the medication and minimise irritation to the intestinal system


4.23 Refer to points 5.4 to 5.7 on the procedure for crushing medication. Administering Medication


4.24 Employees will be supported by employees competent with administering medication until such time as competency based on-job assessment is conducted by the respective Service Manager.


4.25 All medications are administered by employees or by the individual Participant (if they self-administer). Non-prescription medications are administered in accordance with the manufacturer’s instructions.


4.26 It is the responsibility of FLINTWOOD employees to ensure that the medication Management Form and respective charts have been completed by the authorising Medical Practitioner.


4.27 Service Managers are responsible for ensuring the Regular Medication Sign Off form exactly matches the MMP.


4.28 If a Participant takes a medication as a particular time, it is important an alarm is set as a reminder for employees to ensure the medication is given on time.


4.29 It is the responsibility of the Participant, their family, carer/s, or person responsible to ensure that all documentation has been completed according to FLINTWOOD policy and accept that this is the correct medication being provided when entering FLINTWOOD services.


4.30 FLINTWOOD employees will only be responsible for ensuring that the medication provided is administered according to the Medication Management Plan instructions as per the Webster Pak.


4.31 Employees can only administer medication from a Webster Pak (excluding liquids). Employees are not responsible for the contents of the Webster Pak. The Pharmacist has been professionally trained and is responsible for all contents of the Webster Pak.


4.32 Medication(s) cannot be transferred from the originally dispensed package to another container such as an envelope or Dorsett Box.


4.33 A Webster Pak must be provided to ensure there is enough medication for the period FLINTWOOD supports the Participant.


4.34 Grapefruit, apple and orange juice can significantly interact with medication. The effect can lead to either greatly increased or decreased levels of some medications in the bloodstream. Check with the Participant’s GP or Pharmacist for advice.


4.35 Employees are not permitted to carry out any invasive procedures, e.g. rectal Valium, insertion of catheters, suction and injections.


4.36 Refer to points 5.8 to 5.34 for the procedure on how to administer medication. Self Administration


4.37 FLINTWOOD acknowledges the Rights of all Participants accessing FLINTWOOD. Participants will have access to all medical and health services to ensure good and reasonable health.


4.38 Each Participant will have an identified Person Responsible, Carer or Guardian. All of their contact information will be readily accessible.


4.39 FLINTWOOD will act as the Primary carer for the Participants and will be responsible for the day to day support and care provisions of the Participants residing in Supported Accommodation, this includes and may not be limited to coordinating health services, medical appointments, filling prescriptions, administering medication and any supporting Health Professionals as required.


4.40 In any Accommodation model, FLINTWOOD will be responsible for updating Participant medication management forms as required.


4.41 Consent needs to be obtained from the person responsible or guardian acting in the interest of the Participant before any changes to medication or any medical treatment which has not been previously agreed to and a new MMF will need to be completed.


4.42 Consent is accepted either verbally or written. Verbal consent is accepted for short term medications and must be documented and placed on their personal records e.g. antibiotics. Verbal consent will only be valid for that particular point in time and is not to be seen as an ongoing commitment. Written consent must be obtained for all ongoing medications.


4.43 Where possible, all Participants should be encouraged to achieve and maintain maximum independence to administer their own medication. This will occur if they Participant has the capacity to administer his/her own medication and reliably carry out the procedure with only a reminder, guidance and/or minor physical assistance.


4.44 Before a Participant assumes full responsibility for self-administration of medication, the Participant needs to be able to demonstrate they are competent to do so by completing the Medications Participant Self Administration Form. This needs to be reviewed on an annual basis or as the needs and/or capabilities of the Participant change.


4.45 If a Participant has the ability to self-administer their own medication, they must still provide a Medication Management Plan.


4.46 The Service Manager needs to be satisfied that the Participant knows and understands self – medication.


4.47 Participants managing their own medication are supported by employees to make decisions and given access to facilities such as a safe storage area, eg. A lockable drawer / designated area.


4.48 In Accommodation, if a Participant requires Emergency Medical Intervention, it is FLINTWOOD’s responsibility to support the Participant. The Family / Carer, Person Responsible / or Guardian will be notified and consent obtained if any evasive procedures are required.


4.49 FLINTWOOD will be responsible for providing the necessary information concerning a Participants health / medical history to aid medical staff in providing adequate support.


4.50 If at any time FLINTWOOD is not satisfied with the care being provided or a Participants health may be compromised, this needs to be addressed with the appropriate medical staff e.g. medication being prescribed whilst in hospital may contradict routine medication the Participant takes.


4.51 When a Participant we support self administers medication, it does not need to be signed for. Administration of Medication through a feeding tube


4.52 Sometimes a person cannot swallow food or medications and must have these delivered via a feeding tube which is inserted through the abdominal wall.


4.53 A feeding tube is inserted when a person is having difficulty maintaining adequate nutritional intake. There are 3 main types of feeding tubes:

  • Gastronomy
  • Jejunostomy
  • Transgastric jejunostomy

The different names refer to where the tube is positioned inside the digestive tract. Feeding tubes are often referred to as PEG’s however, this refers to one of the methods in which a tube is inserted i.e. Percutaneous Endoscopic Gastronomy, and not the type of tube.




4.55 On discharge from hospital, a follow up consultation with the Participants G.P needs to be conducted to ensure the best possible medical treatment is being provided and to ensure that there will be no negative implications for a Participants health and wellbeing.


4.56 Upon discharge from a hospital, a Doctor’s Authority (or Discharge Letter from the hospital) is an accepted form of Authorisation to administer medication and is valid for a 72 hour period. This will allow for updates to be made to Participants Medication Management Form/charts.



Medication Plan & MMF Form

5.1 The Medication Plan must be reviewed annually or when any changes have been made to a Participants medication regime within this period. It is the responsibility of the Participant / family / person responsible to ensure that all the appropriate documentation is completed correctly in consultation with the authorising Medical Professional.


5.2 MMF’s must be reviewed every 12 months by the prescriber and it is the Participant’s responsibility to have that attended. Do not administer medication after the due date for review has passed.


5.3 Any medical procedure required outside of this policy will require consent of the General Manager and appropriate training. Accepting Medication into FLINTWOOD Services


5.4 Each site is to record all medication being accepted and returned in the Medication Register. Crushing Medication


5.5 Crush and administer one medication at a time. 5.6 Do not mix multiple crushed medications together.


5.7 If unsure if a medication can be crushed, check MMF for specific Dr’s orders, or with the Pharmacist.


5.8 MIMS, Medicines Line, and a “Do not crush” list available from the Pharmacy or online can also be used. Administration of Medication


5.9 All medications must be administered according to a Medical Professional’s orders and pharmacy / manufacturer’s instructions. The medication orders must be clear, legible and not open to misinterpretation.


5.10 Medication in liquid form can be administered by employees. Ensure you follow the Medication Management Form for administration instructions. Where possible, the second employee should confirm that the correct amount of liquid is dispensed prior to administration.


5.11 Employees can phone the prescriber for clarification of a medication order, but cannot take an order over the phone for a new medication.


5.12 If there are any discrepancies the prescribing doctor or the packing pharmacists must be contacted to determine where the error lies. The Service Manager / On Call Manager must be notified and medication will not be administered until the issue has been resolved.


5.13 Where any medication incident occurs contact the Participants GP, Pharmacist, G.P Hotline, Poisons Hot Line, Parents and On Call to determine the next step and also possible consequences for the Participant and how best to monitor during this time.


5.14 An incident report must be completed for every medication incident.


5.15 All medication incidents will be thoroughly investigated and may result in Performance Management.


5.16 Each time you administer medication, you need to be sure to follow the Six Rights of Medication Administration:

Right Participant

Right medication

Right dose

Right time

Right route

Right documentation


5.17 The person responsible / Carer can administer medication on FLINTWOOD premises in a backup or emergency situation. This must be documented on these occasions.


5.18 The days listed on a Webster Pak must match up with days of attendance at the site. If they don’t match, contact the Service Manager or On-Call Manager.


5.19 Where any Participant is to receive a Pro re nata (PRN – for use as required) medication, a Prescribed PRN Medication Sheet must be completed by the Doctor and medication is to be administered according to the directions on the chart. PRN is to be used as a last resort and seeking approval from the Service Manager / On Call.


5.20 PRN is not used as a punishment or for reasons of employee shortages or convenience.


5.21 All incidents of use of PRN are recorded by the employee who administered it.


5.22 If PRN medications are required frequently, the prescribing doctor should be notified.


5.23 Water is usually the best option when administering medication – check meal time plan and MMF for each person you support.


5.24 All regular and prn medications are to be signed for on the regular and prn MMF.


5.25 When recording administration of Webster Pak medications, it is sufficient to write “as per Webster Pack”. Document the dose, route, time to give, signatures and time medication was given.


5.26 Where an error is made in the dispensing of any Participant’s medication, this is recorded on the On Line Incident Reporting system by the employee responsible and following the requirements of incident reporting.


5.27 The Person Responsible must be notified immediately along with the On Call or Service Manager.


5.28 An investigation will occur into the incident in line with the Incident Investigation Policy (refer to Medication Incidents).


5.29 Employees administering medications must sign the Medication chart/ sheet that the medication has been administered.


5.30 Two (2) employees must always be present when administering medication (where this is enabled), with the second employee witnessing and signing that correct dosage is administered at the correct time.


5.31 The new employee who come on to the next shift must always check the medications which were due to be administered during the previous shift, have been administered and clearly documented.


5.32 In the event a Participant refuses to take medication, the employee must contact the person responsible and notify the Service Manager or On call Manager. An incident report is to be completed. Medication cannot be forced into a Participant.


5.33 If medication has not been administered, communication with prior employees, the Service Manager and the family must occur to find out what has happened and an incident form must be completed if a missed medication has occurred.


5.34 In the event that there is only one employee present on shift during the time medication is administered, the employee must check the medication twice, administer and sign for the medication.


5.35 If medication has not been administered, communication with prior employees, the Service Manager and the family must occur to find out what has happened and an incident form must be completed if a missed medication has occurred.


5.36 Employees must ensure they have washed their hands / gloves to be work where medication needs to be handled and physical assistance is required by the Participant to place directly into their mouth.


5.37 To avoid medication being dropped and potential contamination, medication should be dispensed from Webster Pak into a separate container i.e medicine cup.


Tube Feeding


5.38 Only crush medication which is suitable for crushing.


5.39 Crushed medication must be mixed with water to administer


5.40 Tubes need to be regularly flushed to avoid blocking and mixing medication in the tube.


Storage and Security of Medication


5.41 All medication is to be stored in a locked cabinet / cupboard / fridge in the office.


5.42 All medications should be stored in Webster Pak or original containers as dispensed by the pharmacy, and kept together with the MMP and MMF for each Participant.


5.43 When going off-site, medication should be transported in a locked or secure container or bag and treated in accordance with manufacturer’s or pharmacist’s instructions/advice.


Disposal of Medication


5.44 Medication that has expired or is no longer required is returned to the pharmacy for disposal.


5.45 Prior to return to the pharmacy, place tablets in an envelope and store unused/expired medication in a locked cupboard.


5.46 Complete the letter – Returning Medication to Pharmacy and document by putting copy of the letter in the Participant’s file.


5.47 Return the medication to the pharmacy.





  • Checks medication was administered on the shift prior to their shift
  • Is responsible for checking that all medication corresponds with the respective Medication Management Form / Charts.
  • Administer medication in a safe and professional manner
  • Adheres to policy at all times
  • Ensures medication charts are current and signed appropriately
  • Reports concerns to Service Manager
  • Reviews policy and provides feedback


Service Manager

  • Adheres to policy at all times
  • Ensures medication charts are current and signed appropriately
  • All medication is stored in a locked area in the office
  • Reports any concerns to the General Manager
  • Reviews policy and provides feedback
  • Ensure the Regular Medication Sign Off form matches the MMP at all times


General Manager

  • Adheres to policy at all times
  • Educates and trains Service Managers accordingly
  • Make a determination as to whether it is necessary to take counselling and / or disciplinary action
  • Review policy and provide feedback


Human Resources

  • Implement policy across all sites
  • Forward policies and collate feedback for policy committee



  • Adhere to policy at all times
  • Oversee policy development and implementation



A Self Administering Participants

B Staff Administering Medications

C Managing a Medication Incident

D Schedule 8 – controlled drugs

Changes Required:

  • Date Format: MM slash DD slash YYYY

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