# Safe administration of medicines in adult social care

*The six rights, the errors that actually happen, and covert administration done lawfully.*

## Production summary

- Modules to record: 2
- Total script: 1410 words, about 9 minutes of finished audio
- Voices: Amara (host) and Nadia (practice educator)
- Level: Level 2 to 3, care workers and senior carers

## Accreditation wording that must appear in the description

- **The CPD Certification Service** (planned): Application scheduled.
- **NICE guideline SC1 and NG67** (aligned): Written against the NICE guidance on managing medicines in care homes and for people receiving social care in the community. Alignment is our own mapping.

> Do not upgrade any of these words in a description or a thumbnail. Aligned is not accredited, and planned is not approved.


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## The six rights, the MAR and the errors that actually happen

**Runtime** about 5 minutes. **Words** 738. **Starts at** 00:00 in the full course recording.

### Learning outcomes to state on camera

- Apply the six rights before every administration
- Complete a MAR chart correctly including omissions and refusals
- Handle as required medicines, homely remedies and controlled drugs safely
- Report an error honestly and understand why concealment is the greater danger

### Script


`[CUE 1]` *Six rights as six checkpoints along a medication trolley route.*

**AMARA**  [00:00]
Medicines. This is the one that keeps registered managers awake.

**NADIA**  [00:04]
And it should, because medication errors are among the most common causes of avoidable harm in adult social care. But I want to correct something at the start. Most of them are not carelessness.

**AMARA**  [00:17]
What are they then?

**NADIA**  [00:19]
Systems failures. Interruptions. Unclear records. Look alike packaging. Two residents with similar names. Covert administration done without a lawful process. If you design a round badly enough, a conscientious person will still make an error.

**AMARA**  [00:33]
Let me ask something basic. Is social care different from hospital?


`[CUE 2]` *Interruption demonstration: a round interrupted, the error appearing at the next resident.*

**NADIA**  [00:37]
Fundamentally, and nurses moving into social care are caught by this. In social care the medicines belong to the person. You are supporting somebody to take their own medicine, not dispensing from a ward stock.

**AMARA**  [00:51]
Does that change anything practical?

**NADIA**  [00:53]
It changes consent, storage, and above all what happens when they say no. In hospital a refusal is unusual. In somebody's own home it is their medicine, in their house, and refusing is entirely their right.

**AMARA**  [01:08]
The six rights. Run through them.

**NADIA**  [01:10]
Right person. Right medicine. Right dose. Right route. Right time. And right to refuse, which is the one that gets left off the poster. Some services add right documentation and right to know, and both are worth having.


`[CUE 3]` *MAR chart close up showing a coded refusal beside an unexplained blank.*

**AMARA**  [01:25]
Which error is most common?

**NADIA**  [01:27]
Wrong person. And it happens almost exclusively when somebody is interrupted mid round.

**AMARA**  [01:32]
Which happens constantly.

**NADIA**  [01:34]
Constantly. Which is why the single most effective intervention is not more training, it is treating the medication round as an interruption free task. Some services use a red tabard or a do not disturb sign. It looks theatrical, staff feel silly wearing it for about a week, and it measurably reduces errors.

**AMARA**  [01:55]
The MAR chart. What are the rules?


`[CUE 4]` *PRN protocol card with all five required fields.*

**NADIA**  [01:58]
Sign after administering, never before. Never sign for a colleague. And code every omission and refusal rather than leaving a gap.

**AMARA**  [02:06]
Why does a gap matter so much?

**NADIA**  [02:09]
Because afterwards nobody can tell the difference between a dose that was given and not signed for, and a dose that was never given. A gap is not a small administrative untidiness. It is an unanswerable question in an investigation.

**AMARA**  [02:25]
Talk to me about as required medicines. PRN.

**NADIA**  [02:28]
Every one needs a written protocol. What it is for. The dose. The minimum interval. The maximum in twenty four hours. And what to do if it does not work.


`[CUE 5]` *Controlled drugs register with a running balance and two signatures.*

**AMARA**  [02:40]
And without a protocol?

**NADIA**  [02:42]
Then you are making a clinical decision that you are not authorised to make, however experienced you are. And record why you gave it and whether it worked, because that is the only information a prescriber has to work with when they review it.

**AMARA**  [02:59]
Homely remedies?

**NADIA**  [03:00]
Over the counter medicines a service may hold under a written policy agreed with a GP or pharmacist, with a maximum duration before you escalate. It is not a licence to give paracetamol for three weeks because somebody keeps saying their hip aches. At some point that hip needs a doctor.

**AMARA**  [03:20]
Controlled drugs.


`[CUE 6]` *Error response flow, person first, then advice, then report, with concealment crossed out.*

**NADIA**  [03:21]
Register with a running balance. Correct cabinet. Second signature where policy requires. Witnessed disposal. And one absolute rule that I want said very plainly.

**AMARA**  [03:31]
Go on.

**NADIA**  [03:32]
Never adjust a record to make a count balance. Ever. If the numbers do not agree, you report it immediately, that day, even if you are sure it is your own arithmetic. Adjusting the book turns a discrepancy into a falsified record, and that is a dismissal and a referral in every service in the country.

**AMARA**  [03:54]
Which brings me to the last thing. I have made an error. What do I do?

**NADIA**  [04:00]
Check the person first. Always the person before the paperwork. Get clinical advice immediately, whether that is the pharmacist, 111 or 999. Tell your manager. Complete an incident report. Record factually on the MAR.

**AMARA**  [04:14]
And how frightened should I be?

**NADIA**  [04:16]
Less frightened than you are, and I mean that. Here is the thing about medication errors. Most single errors are survivable. A concealed error that delays treatment very often is not.

**AMARA**  [04:29]
So the concealment is the danger, not the error.

**NADIA**  [04:32]
The concealment is the danger. And that puts an obligation on managers as much as on staff. A service that punishes people for errors is a service where errors get hidden. And a service where errors get hidden is a service where somebody eventually dies of something that was entirely fixable in the first twenty minutes.

### Sources for the on screen credit

- Managing medicines in care homes, SC1, NICE
- Managing medicines for adults receiving social care in the community, NG67, NICE
- Misuse of Drugs Regulations 2001, legislation.gov.uk
- Medicines management in adult social care, Care Quality Commission

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## Covert administration and refusal, done lawfully

**Runtime** about 4 minutes. **Words** 672. **Starts at** 04:55 in the full course recording.

### Learning outcomes to state on camera

- Explain when covert administration may lawfully be used
- Describe the full process required before a medicine is given covertly
- Respond to refusal in a person with capacity
- Recognise unlawful covert administration and report it

### Script


`[CUE 1]` *Three conditions card, all required, with capacity first.*

**AMARA**  [04:55]
Covert administration. Just hearing the phrase makes people uncomfortable.

**NADIA**  [04:58]
It should make people careful rather than uncomfortable, because it is sometimes exactly the right thing to do. What is dangerous is doing it casually.

**AMARA**  [05:08]
Define it for me.

**NADIA**  [05:10]
Giving a medicine disguised in food or drink without the person's knowledge or consent. And it is lawful only in narrow circumstances, after a defined process.


`[CUE 2]` *Unlawful example dramatised: yoghurt, tablet, a resident with capacity, marked assault.*

**AMARA**  [05:20]
What are the circumstances?

**NADIA**  [05:22]
Three conditions, all of them required. The person lacks capacity for the specific decision about that medicine. The medicine is necessary for their health. And it has been agreed through a best interests process.

**AMARA**  [05:36]
And if the person has capacity?

**NADIA**  [05:38]
Then it is assault. I want to be as blunt as that, because it is done with kindness all the time. A woman with capacity refuses her tablets, and a carer who cares about her puts them in the yoghurt. That is unlawful, however good the intention, and it is a safeguarding matter.


`[CUE 3]` *Best interests meeting table with prescriber, pharmacist, team, family or advocate.*

**AMARA**  [05:59]
Walk me through the process that has to happen first.

**NADIA**  [06:03]
A capacity assessment for this specific decision, written down. A best interests meeting involving the prescriber, the pharmacist, the care team, and family or an advocate. Consideration of less restrictive options.

**AMARA**  [06:16]
What counts as less restrictive?

**NADIA**  [06:18]
Whether the medicine is still needed at all, which is a question worth asking far more often. Whether the formulation could change, so a liquid or a patch instead of a tablet. Whether the timing could change. Quite often the whole problem is that somebody is being offered eleven tablets at eight in the morning and is overwhelmed.


`[CUE 4]` *Modified release tablet crushed, showing a day's dose released at once.*

**AMARA**  [06:41]
Why does the pharmacist have to be involved?

**NADIA**  [06:44]
Because crushing and mixing is not neutral. It can alter absorption. It is dangerous with modified release preparations, where crushing can deliver a whole day's dose in one go. And it usually takes the medicine outside its product licence, which is a decision a prescriber has to make knowingly.

**AMARA**  [07:04]
And then?

**NADIA**  [07:04]
A written plan. Which medicines, how, in what, by whom. And a review date, because the failure I see most often is not an unlawful start. It is a lawful start that nobody ever revisits, and two years later a person is still being medicated covertly with no one able to say why.


`[CUE 5]` *Covert plan document with a review date circled.*

**AMARA**  [07:26]
Let us go back to refusal in someone with capacity. What am I actually meant to do?

**NADIA**  [07:32]
Not secure compliance. That is not your job and it never was. Your job is to make sure the refusal is informed, find out why, and report it.

**AMARA**  [07:44]
Why does the reason matter so much?

**NADIA**  [07:46]
Because the reason almost always has a fix and the refusal does not. Nausea. A horrible taste. A tablet the size of a sugar cube that they cannot swallow. A belief that this one caused their rash. Depression. Or the commonest of all, that nobody has ever told them what it is for.


`[CUE 6]` *Time critical medicines list with Parkinson's highlighted.*

**AMARA**  [08:08]
That last one is depressing.

**NADIA**  [08:10]
It is very common. And notice that every one of those is solved by a conversation with the prescriber, not by persuasion at the bedside.

**AMARA**  [08:20]
Are there refusals I should escalate immediately?

**NADIA**  [08:22]
Yes, and this list is worth learning. Anticoagulants. Antiepileptics. Insulin. Parkinson's medication. Cardiac medicines. And steroids, where stopping abruptly is dangerous.

**AMARA**  [08:31]
You paused on Parkinson's.

**NADIA**  [08:32]
Because it is the one care settings get wrong most often, and the consequences are fast and severe. Parkinson's medication is time critical. Not roughly on time. Time critical. A dose given an hour late on a busy round can leave somebody unable to move or swallow, and it can take days to get back on top of.

**AMARA**  [08:56]
Last thing. I see a colleague put a tablet in somebody's custard and there is no plan I know of.

**NADIA**  [09:04]
Then that is a safeguarding concern and you report it as one. Not a quiet word. Not a note to the manager next week. It goes down the safeguarding route, exactly as any other concern would, however kindly it was meant and however fond of that resident your colleague is.

### Sources for the on screen credit

- Managing medicines in care homes, SC1, NICE
- Covert administration of medicines, Care Quality Commission
- Mental Capacity Act 2005 Code of Practice, Ministry of Justice
- Parkinson's disease in adults, NG71, NICE

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