Introduction Self administration of medicines has been an area of nursing and pharmacy development. Literature reports have shown that it is feasible, provided appropriate checks are in place and that these happen on a regular basis. Implementation can maintain the patient's independence which is important in the respite setting. It also provides a valuable opportunity to explore adherence where this may be a problem and which could prevent unnecessary admission and the patient being denied the opportunity to be cared for in the place of their choice. Self-administration of high risk drugs such as opioids is an area where further work is required so that inclusion in self-administration schemes is risk-assured and possible.

Aims To establish a framework that facilitates patient self-administration while minimising patient risk.

To further inform governance priorities for self-administration schemes particularly those involving high risk drugs.

Method A multidisciplinary team was formed representing pharmacy, doctors and nurses in order to develop a clinical protocol. Incident surveillance data was used alongside consensus opinion to identify critical stages along the medicines trail and the appropriate control measures to risk manage them.

The protocol manages screening for patient eligibility, consent, monitoring and subsequent management of patients suitable for self-administration. Staff eligibility to undertake this protocol is granted following workshop attendance and completion of evidence-based competencies.

Results and discussion In order to quality-assure the scheme protocol compliance will be audited on a regular basis, results of which will be assessed against incident surveillance data. This will provide ongoing risk management and identify areas for improvement.

Conclusion Trinity hospice has approved this protocol. Staff eligible to undertake a role have been accredited to do so. Under the terms of the hospice's approval an audit of compliance and critical risk assessment will inform the further development of this medicine system.