hospital inpatient self-administration of medicine programmes: a critical literature review
TRANSCRIPT
REVIEW ARTICLE
Hospital inpatient self-administration of medicine programmes:a critical literature review
Julia Wright Æ Angela Emerson Æ Martin Stephens ÆElaine Lennan
Received: 12 October 2004 / Accepted: 3 March 2006 / Published online: 27 September 2006
� Springer Science+Business Media B.V. 2006
Abstract
Aim The Department of Health, pharmaceutical and
nursing bodies have advocated the benefits of self-
administration programmes (SAPs), but their implementa-
tion within UK hospitals has been limited. Perceived
barriers are: anticipated increased workload, insufficient
resources and patient safety concerns. This review aims to
discover if benefits of SAPs are supported in the literature
in relation to risk and resource implications.
Method Electronic databases were searched up to March
2004. Published English language articles that described
and evaluated implementation of an SAP were included.
Outcomes reported were: compliance measures, errors,
knowledge, patient satisfaction, and nursing and pharmacy
time.
Results Most of the 51 papers reviewed had methodo-
logical flaws. SAPs varied widely in content and structure.
Twelve studies (10 controlled) measured compliance by
tablet counts. Of 7 studies subjected to statistical analysis,
four demonstrated a significant difference in compliance
between SAP and controls. Eight studies (5 controlled)
measured errors as an outcome. Of the two evaluated sta-
tistically, only one demonstrated significantly fewer med-
ication errors in the SAP group than in controls. Seventeen
papers (11 controlled) studied the effect of SAPs on pa-
tients’ medication knowledge. Ten of the 11 statistically
analysed studies showed that SAP participants knew sig-
nificantly more about some aspects of their medication than
did controls. Seventeen studies (5 controlled), measured
patient satisfaction. Two studies were statistically analysed
and these studies suggested that patients were satisfied and
preferred SAP. Seven papers studied pharmacy time, three
studied nursing time but results were not compared to
controls.
Conclusions The paucity of well-designed studies, flawed
methodology and inadequate reporting in many papers
make conclusions hard to draw. Conclusive evidence that
SAPs improve compliance was not provided. Although
patients participating in SAPs make errors, small numbers
of patients are often responsible for a large number of er-
rors. Whilst most studies suggest that SAPs increase pa-
tient’s knowledge in part, it is difficult to separate out the
effect of the educational component of many SAPs. Most
patients who participated in SAPs were satisfied with their
care and many would choose to take part in a SAP in the
future. No studies measured the total resource requirement
of implementing and maintaining a SAP.
Keywords Hospital Æ Medication Æ Medicines ÆReview Æ Self-administration
J. Wright (&)
Pharmacy Department, Southampton University Hospitals NHS
Trust, Tremona Road, Southampton, Hants SO16 6YD, UK
e-mail: [email protected]
A. Emerson
Medicines Information Pharmacist-Research and Training,
Wessex Regional Drug and Medicines Information Centre,
Southampton University Hospitals NHS Trust, Southampton,
UK
M. Stephens
Clinical Support Directorate, Southampton University Hospitals
NHS Trust, Southampton, UK
E. Lennan
Southampton Cancer Centre, Southampton University Hospitals
NHS Trust, Southampton, UK
Pharm World Sci (2006) 28:140–151
DOI 10.1007/s11096-006-9014-x
123
Introduction
Hospital inpatient self-administration programmes (SAPs)
in which patients self-administer their own medication
have been reported in the literature since 1959 [1]. The
United Kingdom Nursing and Midwifery Council have
advocated their introduction for many years [2] and the
Ashworth enquiry (1992) supported their use in the reha-
bilitation of hospitalised mental health patients [3]. Recent
publications have also advocated their implementation [4–
6]. In 2002 the Audit Commission produced a briefing
paper [7] and the United Kingdom (UK) Hospital Phar-
macists Group issued guidance on implementing one-stop
dispensing, patients’ own drugs and SAPs to support the
patient-focussed NHS redesign strategy [8]. However,
practice research undertaken at this time [9] suggested
fewer than half UK hospitals had implemented pro-
grammes. Reasons identified for not doing so were insuf-
ficient staff or staff time, and expected increase in nursing
workload. The 2003 Medicines Management in NHS
Hospitals self-assessment framework [10] further audited
whether hospitals had implemented SAPs.
A clear, concise definition of self-administration is dif-
ficult to find. In 1994 the Society of Hospital Pharmacists
of Australia, Committee of Specialty Practice in Rehabil-
itation, suggested that: ‘‘self-medication in a hospital set-
ting means that patients self-administer their medications
under staff supervision whilst in hospital’’ [11]. However,
by 2002 this had been revised to: ‘‘a strategy to identify
and address problems associated with the discharge pro-
cess’’ [12]. The philosophy behind self-administration is
described by Bird and Hassall [13] as being underpinned
by the belief that: ‘‘patients should be as independent as
possible, participate in their own care, make decisions
about their treatment in partnership with nursing and
medical staff and therefore be able to make informed
choices.’’ It is precisely this philosophy of patient care
Audit Commission supports [7] and is a central theme of
the NHS Plan [14]. The conventional method of medicines
administration was designed to protect the patient both
from doctors’ prescribing errors and from nurses’ mistakes
in administration [7]. Bird and Hassall question the tradi-
tional view that the nurse’s role in drug administration is:
‘‘to make sure the right drug is given to the right patient at
the right time’’ [13]; they suggest that nurses could play a
larger part in educating patients about their medicines and
help them to establish routines that work for them at home.
Implementing a SAP, it is argued, gives the nurse an
opportunity to achieve this.
Historically one of the largest barriers to implementing
SAPs has been the concern about patient safety, and
accountability if a patient suffered harm. Another concern
is the resources required to establish and maintain
programmes [9]. Nevertheless, several advantages have
been claimed, including improved patient knowledge about
medicines, improved compliance, improved patient com-
fort and empowerment [7].
Aims
The aim was to establish whether findings in published
literature answered the following questions:
• Do SAPs improve patients’ compliance with their
medication?
• Do SAPs affect risks associated with the medicines
administration?
• Do SAPs improve patients’ knowledge of their medi-
cation?
• Do SAPs improve patients’ satisfaction with their care?
• What resources are needed to implement and maintain
SAPs?
• Do SAPs result in fewer treatment failures?
• Do SAPs result in fewer drug related admissions?
• Do SAPs improve health outcomes?
• Are the benefits equal to or greater than the resources
required?
Method
A literature search was performed electronically. Databases
were accessed in March 2004 and searched back to their
electronic start dates. Searches were limited to the English
language. Search details are given in Table 1. Electronic
searching revealed 455 citations, some of which were
duplicated. Two researchers (JW and AE) performed the
primary selection of articles by studying titles and abstracts
independently, and reached agreement on articles for re-
view from primary sources. Papers were selected only if
they had involved the implementation and subsequent
evaluation of a SAP. One hundred and sixty-eight papers
were selected for review from primary source. Both
researchers read all the articles independently and reached
agreement by discussion on which to select for full review.
Papers were selected if they provided a description of the
SAP and this had been evaluated in an objective manner,
including the presentation of results in the form of quali-
tative or quantitative data. Purely descriptive or anecdotal
articles were excluded. Bibliographies of primary source
papers were examined to identify relevant cited works.
These were collected and screened for inclusion as outlined
above, and added to the set of papers for subject to full
review. A total of 51 papers were selected for full review.
All four researchers independently read the articles se-
Pharm World Sci (2006) 28:140–151 141
123
lected for final critical review. The literature review was
carried out in accordance with an appraisal tool developed
by the national Critical Appraisal Skills Programme
(CASP) collaboration for quantitative methodologies [15].
All four researchers met to discuss and summarise their
findings for each outcome.
Results
Summarised details of the primary studies reviewed and
outcomes are presented in Table 2. A more detailed table
including clinical specialty, study design and sample size,
evaluation methods and statistical details is available from
the authors on request.
Published literature reviews
One English language review of published literature was
found [63]. This search was limited to nursing databases
for 1983 to 1995 and found 12 empirical studies. Ten were
quasi-experimental, and two were action research. Eleven
non-empirical studies were also reviewed. Although the
research question and outcomes for this review were un-
clear, the authors concluded that, in spite of methodologi-
cal shortcomings, the outcomes from all the 12 empirical
studies substantiated findings from the non-empirical work:
that SAPs increased patients’ knowledge of drug regimens,
names and frequency of administration, but not their
knowledge of side effects. Additionally, they noted a
positive association between SAPs and improved compli-
ance in all but one study [16]. However, all studies in-
cluded in this review were judged by us to be of poor
quality. Four were excluded from this review in the second
sampling process.
Types of self-administration programmes
Self-administration programmes described in the literature
varied widely in their structure and content. Some had
many levels for a patient to complete, from patient
selection or request for medication, to periods of self-
administration monitored by nurses, to un-monitored self-
administration. The length of time spent at each level also
varied and could be either programme or patient specific.
Programmes in rehabilitation settings often required
patients to complete several levels over lengthy periods,
whereas those on acute settings usually comprised only one
level. Some programmes were designed for patients to
complete all levels before discharge. Indeed, being able to
successfully complete the final level of a rehabilitation
programme could be an indicator that a patient is ready for
discharge into the community, or to determine the level of
support required on discharge [64]. In more acute settings,
Table 1 Search strategy
Databases Date Search terms
Zetoc 1993 to Mar 2004 Self-administration and hospital
Self-medication and hospital
Cochrane Library [1] [2003]. Chichester, UK:
John Wiley and Sons Ltd.
Not stated Self-administration and hospitals
Self-medication and hospitals
Pharmline 1978 to Mar 2004 Self-administration
Self-medication
Embase via OVID 1980 to Mar 2004 Drug-self-administration * and hospital *
Self-medication * and hospital *
Medline via OVID 1966 to Mar 2004 Self-administration * and hospitals *
Self-medication * and hospitals *
Cinahl via OVID 1982 to Mar 2004 Self-administration * and hospitals *
Self-medication * and hospitals *
EPIC 1992 to Mar 2004 Performed by the Royal Pharmaceutical
Society of Great Britain
IPAB 1970 to Mar 2004 Performed by the Royal Pharmaceutical
Society of Great Britain
ScHARR http://www.shef.ac.uk/~scharr/ir/netting/ No date specified Self-administration
Self-medication
Drug-self-administration
British Library Thesis Index 1970 to Mar 2004 Self-administration and hospital
Self-medication and hospital
Department of Health websites http://www.doh.gov.uk/index.htm No date specified Self-administration
Self-medication
Agency for healthcare research and quality http://www.ahcpr.gov/ No date specified Self-administration
Self-medication
Drug-self-administration
* = Exploded term
142 Pharm World Sci (2006) 28:140–151
123
Ta
ble
2R
esu
lts
Au
tho
rO
utc
om
eR
esu
lts
Pro
os
[16]
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mp
lian
ceN
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gn
ifica
nt
dif
fere
nce
sin
com
pli
ance
sco
res
for
self
-ad
min
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gg
rou
p(S
AG
)co
mp
ared
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ach
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gro
up
Kn
ow
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Gh
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ses
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ean
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res
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rn
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cy,
pu
rpo
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de
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cts.
Bo
thg
rou
ps
had
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her
kn
ow
led
ge
sco
res
atd
isch
arg
e
Co
le[1
7]
Co
mp
lian
ce9
2%
pat
ien
tsre
ceiv
ing
nu
rse
adm
inis
trat
ion
wit
hd
isch
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un
sell
ing
and
88
%o
fS
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jud
ged
tob
ead
min
iste
rin
gco
rrec
tly
ver
sus
24
%co
ntr
ols
Ph
arm
acy
tim
e
Ph
arm
acis
tn
eed
ed1
5m
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erp
atie
nt
for
un
com
pli
cate
d,
and
30
–4
5m
info
rco
mp
lica
ted
dis
char
ge
con
sult
atio
ns
D’A
ltro
y[1
8]
Co
mp
lian
ceS
ign
ifica
ntl
ym
ore
pat
ien
tsra
ted
asco
mp
lian
tan
dp
arti
ally
com
pli
ant
inS
AG
com
par
edto
con
tro
ls.
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nifi
can
tly
few
erp
atie
nts
rate
das
no
n-c
om
pli
ant
in
SA
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ersu
sco
ntr
ol
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rdsl
ey[1
9]
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mp
lian
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sig
nifi
can
tly
mo
reco
mp
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tco
mp
ared
toco
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ols
Kn
ow
led
ge
SA
Gk
new
sig
nifi
can
tly
mo
reab
ou
tth
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dru
gs
than
con
tro
ls
Bir
d[2
0]
Co
mp
lian
ceM
ore
pat
ien
tsin
SA
Gco
mp
ared
toco
ntr
ol
had
corr
ect
nu
mb
ero
fta
ble
tsre
mai
nin
g
Kn
ow
led
ge
SA
Gg
rou
psc
ore
dm
ore
corr
ect
answ
ers
on
kn
ow
led
ge
of
dru
gp
urp
ose
and
sid
eef
fect
sth
anco
ntr
ols
Wo
od
[21
]C
om
pli
ance
Sig
nifi
can
tly
few
erp
atie
nts
rate
das
no
n-c
om
pli
ant
inS
AG
com
par
edto
con
tro
ls.
Co
ntr
ols
mad
em
ore
seri
ou
ser
rors
Fo
ster
[22]
Co
mp
lian
ceN
osi
gn
ifica
nt
dif
fere
nce
sin
com
pli
ance
bet
wee
nS
AG
and
con
tro
ls
Lo
we
[23
]C
om
pli
ance
Mea
nco
mp
lian
cesc
ore
sig
nifi
can
tly
hig
her
inS
AG
com
par
edto
con
tro
ls
Kn
ow
led
ge
Sig
nifi
can
tly
mo
reS
AG
pat
ien
tsk
new
the
pu
rpo
seo
fth
eir
med
icat
ion
com
par
edto
con
tro
ls
Sat
isfa
ctio
n9
5%
SA
Gp
refe
rred
self
-ad
min
istr
atio
n.
88
%fe
ltm
ore
inco
ntr
ol
of
thei
rm
edic
ines
.4
3%
felt
mo
reco
nfi
den
tta
kin
gth
eir
med
icin
es
Day
[24
]C
om
pli
ance
No
dif
fere
nce
inm
ean
com
pli
ance
sco
reb
etw
een
SA
Gan
dco
ntr
ols
Jen
sen
[25]
Co
mp
lian
ceN
osi
gn
ifica
nt
dif
fere
nce
sin
adh
eren
cesc
ore
sb
etw
een
SA
Gan
dco
ntr
ols
Kn
ow
led
ge
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nifi
can
tin
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ses
inm
edic
atio
nk
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wle
dg
eac
ross
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rb
oth
gro
up
sb
ut
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ease
ssi
gn
ifica
ntl
yh
igh
erin
SA
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mp
ared
toco
ntr
ols
Sat
isfa
ctio
n7
3.7
%p
atie
nts
inb
oth
gro
up
sp
refe
rred
self
-ad
min
istr
atio
n.
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nifi
can
tly
hig
her
sco
res
for
SA
Gco
mp
ared
toco
ntr
ols
for
9/2
0q
ues
tio
ns
Car
ter
[26
]C
om
pli
ance
40
%w
ho
self
-ad
min
iste
red
rate
das
full
yco
mp
lian
t;3
0%
par
tial
lyco
mp
lian
t;2
0%
no
n-c
om
pli
ant
des
pit
ep
rolo
ng
eded
uca
tio
n
Han
nay
[27]
Co
mp
lian
ceA
ver
age
adh
eren
cera
tein
self
-ad
min
iste
rin
gp
atie
nts
was
83
%
Wan
dle
ss[2
8]
Err
ors
Sel
f-ad
min
iste
rin
gp
atie
nts
giv
enre
min
der
card
san
dta
ble
tid
enti
fier
sm
ade
sig
nifi
can
tly
few
erer
rors
than
tho
sen
ot
giv
enm
emo
ryai
ds
Rei
bel
[29]
Err
ors
12
8er
rors
in1
71
5o
pp
ort
un
itie
s.8
5%
erro
rsw
ere
om
issi
on
s.1
3p
atie
nts
mad
en
oer
rors
.7
mad
eer
rors
>1
0%
of
the
tim
e,ac
cou
nti
ng
for
87
%to
tal
erro
rs
Sat
isfa
ctio
nA
llp
atie
nts
wh
ose
lf-a
dm
inis
tere
dre
com
men
ded
the
pro
gra
mm
eb
eco
nti
nu
ed
Lib
ow
[30]
Err
ors
14
erro
rsin
58
8o
pp
ort
un
itie
s.O
ne
pat
ien
tm
ade
6er
rors
Ro
ber
ts[3
1]
Err
ors
Inad
min
iste
rin
g1
13
5d
ose
s,n
urs
esm
ade
21
erro
rs,
and
tech
nic
ian
s6
.T
ech
nic
ian
sm
ade
7er
rors
inm
on
ito
rin
g6
3d
ose
s.N
urs
esm
ade
17
erro
rsin
mo
nit
ori
ng
56
do
ses.
Sel
f-ad
min
iste
rin
gp
atie
nts
mad
e15
4er
rors
ou
to
f3
54
8d
ose
s.9
pat
ien
tsm
ade
no
erro
rs
Dav
idso
n[3
2]
Err
or
Pat
ien
tsse
lf-a
dm
inis
teri
ng
mad
eer
rors
irre
spec
tiv
eo
fw
het
her
they
had
are
min
der
card
New
com
er[3
3]
Err
ors
No
sig
nifi
can
td
iffe
ren
cein
mis
sed
do
ses
for
SA
Gco
mp
ared
toco
ntr
ols
Kn
ow
led
ge
Sig
nifi
can
tim
pro
vem
ent
ink
no
wle
dg
ein
SA
Gco
mp
ared
toco
ntr
ols
for:
dru
gn
ames
,ti
me
tota
ke,
adv
erse
reac
tio
ns
and
sid
eef
fect
s
Sh
ann
on
[34
]E
rro
rS
AG
mad
e4
4er
rors
and
con
tro
lm
ade
10
5.
Th
ree
pat
ien
tsin
SA
Gan
d4
con
tro
lsm
ade
no
erro
rs.
Tw
oco
ntr
ol
pat
ien
tsm
ade
ato
tal
of
88
erro
rs
Per
eles
[35]
Err
ors
SA
Gm
ade
sig
nifi
can
tly
few
erto
tal
erro
rsth
anco
ntr
ols
.N
osi
gn
ifica
nt
dif
fere
nce
bet
wee
ng
rou
ps
inp
rop
ort
ion
of
seri
ou
ser
rors
mad
e
Kn
ow
led
ge
Sig
nifi
can
tk
no
wle
dg
eg
ain
acro
ssti
me
for
SA
Gan
dco
ntr
ols
inal
lca
teg
ori
esex
cep
tsi
de
effe
cts.
No
dif
fere
nce
sin
kn
ow
led
ge
bet
wee
ng
roup
s
Bre
am[3
6]
Kn
ow
led
ge
Lar
ger
incr
ease
sin
kn
ow
led
ge
rep
ort
edin
SA
Gco
mp
ared
toco
ntr
ols
Lea
db
eate
r[3
7]
Kn
ow
led
ge
SA
Gsc
ore
da
gre
ater
per
cen
tag
en
um
ber
of
corr
ect
answ
ers
on
kn
ow
led
ge
of
dru
gn
ame,
pu
rpo
sean
dsi
de
effe
cts
than
con
tro
ls
Sat
isfa
ctio
n9
3%
SA
Gco
mp
ared
to2
0%
con
tro
lsw
ou
ldch
oo
sese
lf-a
dm
inis
trat
ion
Bar
ry[3
8]
Kn
ow
led
ge
SA
Gk
no
wle
dg
eim
pro
ved
in4
ou
to
f6
cate
go
ries
.B
oth
gro
up
ssc
ore
dh
igh
on
tim
eo
fd
ose
s,n
ame
and
pu
rpo
se
Fu
rlo
ng
[39
]K
no
wle
dg
eS
ign
ifica
nt
gai
nin
kn
ow
led
ge
acro
ssti
me
for
SA
Gan
dco
ntr
ol
exce
pt
sid
eef
fect
s.W
her
eth
ere
wer
esi
gn
ifica
nt
dif
fere
nce
sb
etw
een
gro
up
s,k
no
wle
dg
ew
as
bet
ter
inco
ntr
ol
gro
up
Sat
isfa
ctio
n8
6%
SA
Gp
refe
rred
self
-ad
min
istr
atio
nan
d9
0%
wer
esa
tisfi
edw
ith
the
pro
gra
mm
e.A
llco
ntr
ols
pre
ferr
edn
urs
ead
min
istr
atio
n
Ho
ffm
an[4
0]
Kn
ow
led
ge
Sta
tist
ical
lysi
gn
ifica
nt
incr
ease
sin
kn
ow
led
ge
acro
ssti
me
for
5o
ut
of
10
qu
esti
on
sin
pat
ien
tsw
ho
self
-ad
min
iste
red
Sat
isfa
ctio
n9
8%
pat
ien
tsw
ho
self
-ad
min
iste
red
lik
edth
ep
rog
ram
me
and
felt
they
had
lear
nt
abo
ut
thei
rm
edic
ines
Pel
leti
er[4
1]
Kn
ow
led
ge
Pat
ien
tsw
ho
self
-ad
min
iste
red
sho
wed
sig
nifi
can
tk
no
wle
dg
eim
pro
vem
ent
acro
ssti
me
for
dru
gn
ame,
use
,ap
pea
ran
cean
dti
me
of
adm
inis
trat
ion
Pharm World Sci (2006) 28:140–151 143
123
Ta
ble
2co
nti
nu
ed
Au
tho
rO
utc
om
eR
esu
lts
Th
om
as[4
2]
Kn
ow
led
ge
Pat
ien
tsw
ho
self
-ad
min
iste
red
sho
wed
sig
nifi
can
tk
no
wle
dg
eim
pro
vem
ent
acro
ssti
me
tod
isch
arg
e,b
ut
no
furt
her
imp
rov
emen
tp
ost
-dis
char
ge
Ng
[43
]K
no
wle
dg
eP
atie
nts
wh
ose
lf-a
dm
inis
tere
dsh
ow
edsi
gn
ifica
nt
kn
ow
led
ge
imp
rov
emen
tac
ross
tim
eab
ou
tsi
de
effe
cts
No
y[4
4]
Kn
ow
led
ge
Gen
eral
tren
dto
war
ds
anin
crea
sein
kn
ow
led
ge
inp
atie
nts
wh
ose
lf-a
dm
inis
tere
dac
ross
tim
e
Tra
iger
[45
]K
no
wle
dg
e8
0%
of
all
pat
ien
tsw
ho
self
-ad
min
iste
red
cou
ldv
erb
alis
eal
lre
qu
ired
info
rmat
ion
Sat
isfa
ctio
n1
00
%S
AG
ver
sus
78
%co
ntr
ols
felt
con
fid
ent
abo
ut
tak
ing
thei
rm
edic
ines
on
dis
char
ge.
10
0%
SA
Gv
ersu
s8
1%
con
tro
lsk
new
the
med
icin
ep
urp
ose
Bu
chan
an[4
6]
Sat
isfa
ctio
n7
6%
pat
ien
tsw
ho
self
-ad
min
iste
red
pre
ferr
edth
isco
mp
ared
ton
urs
ead
min
istr
atio
n.
69
%fe
ltit
hel
ped
them
tom
anag
eb
ette
rat
ho
me
Sto
nn
ing
ton
[47]
Sat
isfa
ctio
n7
9%
pat
ien
tsw
ho
self
-ad
min
iste
red
felt
ith
elp
edth
emto
un
der
stan
dth
eir
med
icat
ion
.8
2%
felt
itim
pro
ved
thei
rfe
elin
go
fin
dep
enden
ce
Ny
nic
k[4
8]
Sat
isfa
ctio
nP
atie
nts
wh
ose
lf-a
dm
inis
tere
dp
refe
rred
itb
ya
5to
1m
arg
ino
ver
pre
vio
us
met
ho
ds
for
pai
nan
dco
nst
ipat
ion
reli
ef
An
der
son
[49]
Sat
isfa
ctio
n8
2%
pat
ien
tsw
ho
self
-ad
min
iste
red
reac
ted
po
siti
vel
yto
the
pro
gra
mm
e
Nu
rsin
gti
me
Pat
ien
tsn
eed
edan
aver
age
of
15
min
inst
ruct
ion
bef
ore
star
tin
gth
ep
rog
ram
me.
No
red
uct
ion
inn
urs
ing
tim
efo
rad
min
istr
atio
n
Bo
rnst
ein
[50
]S
atis
fact
ion
All
pat
ien
tsw
ho
self
-ad
min
iste
red
pre
ferr
edit
ton
urs
ead
min
istr
atio
n.
All
felt
pre
par
edto
self
-ad
min
iste
rco
rrec
tly
ath
om
e
Kal
las
[51]
Sat
isfa
ctio
n8
4%
pat
ien
tsw
ho
self
-ad
min
iste
red
fou
nd
the
pro
gra
mm
eh
elp
ful
and
felt
that
they
had
lear
nt
abo
ut
thei
rm
edic
ines
Jan
ko
wsk
i[5
2]
Sat
isfa
ctio
nA
llp
atie
nts
wh
ose
lf-a
dm
inis
tere
dsa
idth
eyw
ou
ldp
arti
cip
ate
agai
nan
dal
lfe
ltit
was
easi
erto
tak
eth
eir
med
icin
esat
ho
me
Pta
shn
ick
[53
]S
atis
fact
ion
87
%p
atie
nts
wh
ose
lf-a
dm
inis
tere
dfe
ltth
eyh
adb
enefi
ted
fro
mth
ep
rog
ram
me
Su
ther
lan
d[5
4]
Sat
isfa
ctio
nM
ost
pat
ien
tsw
ho
self
-ad
min
iste
red
wer
esa
tisfi
edw
ith
the
pro
gra
mm
e
Dee
ks
[55]
Sat
isfa
ctio
nS
AG
rep
ort
edsi
gn
ifica
ntl
yb
ette
ro
ver
all
imp
ress
ion
of
care
,an
dsc
ore
dh
igh
ero
nfe
elin
gs
on
dis
char
ge,
wit
hsi
gn
ifica
ntl
yh
igh
erm
ean
dis
char
ge
sati
sfac
tio
nin
dic
esv
ersu
sco
ntr
ols
.N
od
iffe
ren
ceb
etw
een
mea
nsa
tisf
acti
on
ind
ices
for
the
pro
vis
ion
of
info
rmat
ion
abo
ut
med
icin
esfo
rea
chg
rou
p.
80
.9%
SA
Gw
ou
ldch
ose
self
-ad
min
istr
atio
nag
ain
inth
efu
ture
and
wo
uld
be
sig
nifi
can
tly
mo
reli
kel
yto
do
so,
ver
sus
con
tro
ls.
SA
Gw
assi
gn
ifica
ntl
y
yo
un
ger
than
con
tro
ls.
Yo
un
ger
con
tro
lssh
ow
eda
sig
nifi
can
tly
gre
ater
des
ire
tose
lf-a
dm
inis
ter
inth
efu
ture
com
par
edto
old
erp
atie
nts
Joh
nso
n[5
6]
Ph
arm
acy
tim
e4
–5
ho
fp
har
mac
ist
tim
ew
asre
qu
ired
on
the
war
dp
erd
ay.
Ph
arm
acis
tm
on
ito
red
com
pli
ance
and
dis
pen
sed
med
icat
ion
Lu
caro
tti
[57]
Ph
arm
acy
tim
e2
4m
inp
har
mac
ist
tim
ep
erp
atie
nt
req
uir
edfo
rth
ose
on
anav
erag
eo
f2
med
icat
ion
s,p
lus
10
min
dis
pen
sin
gti
me.
Inan
8-h
shif
t,an
aver
age
of
10
7m
inw
assp
ent
on
2w
ard
s.5
8%
of
this
was
spen
to
nth
ep
rog
ram
me
Tay
lor
[58
]P
har
mac
yti
me
Ph
arm
acis
tsp
ent
aver
age
30
min
dai
lyco
un
sell
ing
2–
3p
atie
nts
Wal
ker
[59
]P
har
mac
yti
me
50
–6
0m
ino
fp
har
mac
ist
tim
ew
asre
qu
ired
tost
art
ap
atie
nt
on
the
pro
gra
mm
e
Bea
um
on
t[6
0]
Ph
arm
acy
tim
eT
ech
nic
ian
spen
t1
05
min
per
wee
kd
isp
ensi
ng
pre
scri
pti
on
s.P
har
mac
ist
spen
t9
0m
inp
erw
eek
chec
kin
gp
resc
rip
tio
ns
and
pre
par
ing
info
rmat
ion
shee
ts
Nu
rsin
gti
me
48
min
nu
rsin
gti
me
req
uir
edp
erp
atie
nt
bef
ore
ente
rin
gp
rog
ram
me
and
up
to1
2m
inp
erp
atie
nt
per
day
dep
end
ing
on
stag
eo
fS
AP
.N
urs
e-
adm
inis
trat
ion
req
uir
ed6
min
nu
rsin
gti
me
per
pat
ien
tp
erd
ay
Pea
rce
[61
]P
har
mac
yti
me
Ad
dit
ion
al1
0m
inp
erp
atie
nt
ph
arm
acis
tti
me
req
uir
edo
nw
ard
and
10
.4m
inp
erp
atie
nt
dis
pen
sin
gti
me.
To
tal
extr
ap
har
mac
yw
ork
load
esti
mat
edat
3h
per
wee
kfo
rtu
rno
ver
of
8p
atie
nts
,in
clu
din
g1
.5h
ph
arm
acis
tti
me
on
war
d
Pla
tts
[62
]N
urs
ing
tim
e4
8m
inn
urs
ing
tim
ere
qu
ired
per
pat
ien
tb
efo
reen
teri
ng
pro
gra
mm
ean
du
pto
18
min
per
pat
ien
tp
erd
ayd
epen
din
go
nst
age
of
SA
P.
Nu
rse-
adm
inis
trat
ion
req
uir
ed6
min
nu
rsin
gti
me
per
pat
ien
tp
erd
ay
144 Pharm World Sci (2006) 28:140–151
123
patients may be discharged before programme completion.
Most programmes contained elements of information pro-
vision and patient education, ranging from verbal coun-
selling by staff, through written information sheets and
information leaflets, to provision of diary cards, record
sheets and compliance aids. SAPs are varied and complex
interventions and this needs considering when reviewing
studies.
Discussion
Do SAPs improve patients’ compliance with their
medication?
Research into compliance is hampered because rates often
vary between treatments and over time for the same indi-
viduals [65]. Parkin [66] suggests that more patients
deviate from prescribed regimens after hospital discharge
due to non-comprehension than intentional non-
compliance. Twelve papers measured the effect on
compliance as an outcome [16–27]. Nine studies were
controlled [17–25], two uncontrolled [26, 27], and one
compared a SAP with a structured teaching programme
[16]. All samples were small; the largest [25] contained
178 patients in the experimental arm. Ten studies followed
patients up post-discharge, at time intervals ranging from
1 week to 4 months post-discharge and two studies con-
tained inpatients only [26, 27]. Tablet counts were used to
assess compliance in all studies. A drawback with these are
that patients may adjust numbers of tablets either deliber-
ately or inadvertently. In addition, different types of
administration errors may cancel out [28] e.g. an overdose
may cancel an error of omission; errors concerning timing
will not be detected. More covert approaches can encounter
ethical issues regarding informed consent [67]. In 10
studies counts were performed directly by the investigators.
The remaining two, relied on patient counts or the inves-
tigators’ judgement [17, 25]. Both these methods have been
shown to over-estimate compliance [68]. None of the
studies described how medication prescribed ‘‘as re-
quired’’ was assessed.
The methods used for rating patients as ‘‘compliant’’
varied. In four studies [16, 23, 24, 26] a compliance score
was calculated for each patient as the percentage correct
number of tablets remaining and it is assumed that Foster
et al. [22] used a similar methodology. This allows com-
parison between individual patients and groups. Jensen
[25] used a more complex calculation to score adherence
and Hannay [27] calculated an average compliance score
for the group. One study [20] measured the number of
patients having the correct number of tablets remaining.
Use of absolute ratings of compliance means that a patient
making one error, could be rated non-compliant in the
same way as a patient making many. Two authors [18, 19]
used ‘‘days deviation’’ in therapy as measures and pooled
data. The remaining study [21] measured numbers of
errors made then calculated an average percentage of non-
compliance to assign patients to one of three compliance
levels.
Of the studies subjected to statistical analysis, four
reported a significant difference [18, 19, 21, 23]. Although
a P value of 0.02 is quoted by D’Altroy et al., it is not clear
whether this relates to significance between both groups at
all levels of compliance. Beardsley et al. [19] found sig-
nificant differences (P < 0.01, t-test) in mean numbers of
‘‘deviation in days’’ treatment between the self-
administration group (1.8 days deviation) and controls
(3.6 days deviation). Wood et al. [21] reported signifi-
cantly more patients with greater than 15% non-compli-
ance in controls compared to the study group at 2 weeks
post-discharge (P < 0.02) and at 3 months post-discharge
(P < 0.05 chi-squared and Fisher’s exact tests). However,
the patient numbers in all groups were small and no sig-
nificant differences were found between the results for
patients with less than 15% non-compliance. Lowe et al.
[23] reported significantly better compliance scores for the
self-administration group compared to controls at 10 days
post-discharge (95% compared to 83%; P < 0.02 Mann–
Whitney U). Two studies [22, 25] reported no significant
difference in percentage compliance scores between the
study and control groups. One of these [22] is quoted in ‘‘A
spoonful of Sugar’’ [6] as supporting the hypothesis that
SAPs improve patient compliance. Proos et al. [16]
reported no significant difference in compliance scores
between a group of patients receiving a structured educa-
tion programme and a group participating in a SAP. Whilst
the results from the studies are inconclusive, it is evident
that some patients will comply and others will have sig-
nificant non-compliance problems irrespective of whether
they participate in a SAP.
Do SAPs affect risks associated with medicines
administration?
Medication errors can be considered a measure of risk as
well as non-compliance. Eight studies measuring errors
were reviewed [28–35]. Design and methodology varied
considerably. Six studies used tablet counts [28, 30–32, 34,
35], one used disguised observation [31] and two used
structured interviews [29, 33]. Five studies were controlled,
three of these [33–35] were randomised and followed up
patients after discharge; however, randomisation broke
down in one [34]. Pereles et al. [35] claimed a ‘‘significant
Pharm World Sci (2006) 28:140–151 145
123
improvement in compliance for the self-administration
group as measured by the proportion of medication errors
of the total doses administered (0.045 vs. 0.086,
P < 0.001)’’. Details of the total numbers of errors made
and total doses are not provided, only averages. However,
the numbers of serious errors (with a potential for health
risk) were analysed separately and not found to be statis-
tically different between groups. All serious errors were
errors of omission, it is unclear how this methodology
would have captured other types of error. Newcomer and
Anderson [33] failed to demonstrate a significant differ-
ence in missed doses between groups, but details of
methodology are lacking. Studies containing larger patient
numbers [33, 35] lost approximately one third of patients to
follow up.
Davidson’s controlled study [32], is limited by small
patient numbers and short timescale. Wandless and Davie
[28], found patients using written reminders made statis-
tically fewer errors in self-administration than those with-
out reminders.
Only one study [31] compared errors made by patients
with those made by nurses and technicians. Out of 1135
administered doses, nurses made 21errors (3.86% error
rate) and technicians made six (1.02% error rate). Seven-
teen errors of omission and 10 errors of commission (any
dose incorrectly administered as a wrong or unscheduled
drug or wrong dose) were made. The self-administering
group made 153 errors in administering 3548 doses (4.3%
error rate). All these were errors of omission, but the study
design prevented detection of errors in dosing and timing.
All the errors were made by six patients; nine made no
errors. Although Shannon’s study [34] contained small
numbers in each group, 3 out of 11 study patients and 4 out
of 10 controls made no errors, and 88 out of a total of 105
errors made by controls, were made by 2 patients. If data
from these two patients were to be excluded, the control
group would have made fewer errors than the study group.
Reibel [29] reported that 7 patients made errors accounting
for 87% of total errors, and an unusual study by Libow and
Mehl [30], in which patients self-administered two sets of
placebo medication, also demonstrated that a high pro-
portion of total errors were made by one patient who re-
quired correction almost every day. This illustrates the
need to consider the range of the data in relation to indi-
vidual patients, before drawing conclusions from pooled
data alone.
Do SAPs improve patients’ knowledge of their
medicines?
Seventeen papers [16, 19, 20, 23, 25, 33, 35–45] were
selected for review that studied the effect of a SAP on
patients’ knowledge about their medicines. Five were
randomised and controlled [20, 23, 33, 35, 36], five were
controlled [19, 25, 37–39] and five were designed only to
test patient knowledge before and after taking part in the
programme [40–44]. A further randomised, controlled
study [16] compared the effect of a structured teaching
programme with a SAP on patients’ knowledge. Traiger
and Bui’s [45] uncontrolled study only measured patients’
knowledge at discharge and is thus methodologically
flawed.
SAPs’ structure varied and included verbal counselling
with or without additional written information or remind-
ers. Three randomised controlled studies measured
knowledge at a single point in time [20, 23, 33], and sev-
eral studies utilised a before-and-after design, testing
knowledge at more than one point. Whilst enabling base-
line measurements to be used for stratifying or matching
variables, it may introduce bias by sensitising patients
during the baseline measurements. This effect is likely to
be greater in studies where knowledge is tested more than
twice. Before-and-after designs are methodologically weak
because secular trends or other concurrent changes make it
difficult to attribute observed changes to the intervention
being studied [69].
Two studies [42, 44] used written questionnaires, mix-
ing open and closed questions. Fifteen [16, 19, 20, 23, 25,
33, 35–41, 43, 45] used verbal questioning or question-
naires. Of these, 14 used open questions and one closed
[40]. In the studies using open questions, details of how
questions were scored are only described in five of the
papers [16, 36, 39, 41, 43]. Details of questions and
questionnaires were provided in 10 studies [16, 25, 35,
38–44].
The use of structured interviews is subject to interviewer
bias although this can be reduced if an independent re-
searcher is used. Inter-rater reliability can also be prob-
lematic. Hoffman et al. [40] used a 10 point questionnaire
was used that required true/false answers, thus having a
50% chance of correct guess. In the randomised, controlled
studies, Newcomer and Anderson [33] reported statistically
significant improvement in patients’ knowledge of drug
names, time to take, adverse reactions (P < 0.005) and side
effects (P < 0.0025), details of the evaluation methodology
are lacking. Lowe et al. [23] found a statistically significant
increase in patients’ knowledge of their medication pur-
pose. Pereles et al. [35] reported statistically significant
gains in knowledge over time for drug names, appearance,
time to take and purpose in both the study and control
groups, but no significant differences in knowledge of side
effects. However, no significant differences were found in
any of the parameters between the groups, implying that
patients will learn over time irrespective of the system.
146 Pharm World Sci (2006) 28:140–151
123
In the controlled studies, Jensen [25] reported significant
increases in knowledge in both study and control groups
from admission to 16 weeks post-discharge, with signifi-
cantly higher scores in the study compared to control
group. Beardsley et al. [19] reported statistically significant
differences between study and control groups in the
‘‘number of questions missed regarding knowledge of
treatment’’ at 1-month post-discharge follow-up. Scores
out of a possible 60 points are quoted, however, details of
questions and methods are lacking. Furlong [39] reported
statistically significant differences in knowledge gain in
both groups for drug name and dose, and purpose, from
admission to 8-week post-discharge, and for time to take,
in just the study group. Neither group showed significant
differences in increased knowledge regarding side effects;
there were no significant differences between the groups.
No P values are quoted for any differences stated and the
control group was small. The data regarding knowledge
and numbers of medications were assessed collectively for
each group and analysed using chi-squared tests. The au-
thors acknowledge that multiple testing may have led to
type 1 error resulting in spuriously significant findings.
The results of four out of the five uncontrolled studies,
comparing differences in patients’ knowledge before and
after having taken part in a SAP, were analysed statistically
[40–43]. Hoffman et al. [40] reported statistically signifi-
cant increases in knowledge for 5 out of 10 questions
requiring true/false answers relating to post-partum stand-
ing order medication. In addition, the percentage of correct
answers in post-test scores increased for each question.
Pelletier et al. [41] reported statistically significant differ-
ences in knowledge from admission to discharge, in drug
name, appearance, purpose and time to take and less
improvement in drug strength, however, the standard
deviations quoted are all well in excess of the mean dif-
ferences stated. In the study by Ng et al. [43], statistically
significant improvement in knowledge regarding side ef-
fects and compliance concerns was reported, but no dif-
ference in improvement in knowledge concerning regimen
and purpose. However, details of the statistical evaluation
are not stated, the number of patients is small and the study
period was only 1 week.
As most programmes contain some provision of infor-
mation to patients either in the form of verbal counselling
or explanation, written information leaflets or diary re-
minder cards, it is difficult to ascertain whether it is the
education component of the programme that has the most
impact on increasing knowledge or whether it is because
the patient is responsible for taking their own medication
or a combination of the two. Two uncontrolled studies
attempted to investigate this. Thomas et al. [42] measured
knowledge at five points: on entry to the study, then fol-
lowing an educational programme, then following a SAP
at discharge and 1 month following discharge. Statistically
significant differences in percentage correct answers were
reported on entry, compared to after an education pro-
gramme (P < 0.01) and prior to commencing self-admin-
istration compared to discharge (P < 0.05), but no
significant differences between scores were achieved from
discharge to 1-month post-discharge follow-up. The largest
average percentage change in test scores was obtained
between entry to the study and post-education, suggesting
that education about medicines contributes more to
knowledge gain than participation in a SAP, although the
results also suggest that there was some additional gain in
knowledge during the programme. The randomised con-
trolled study by Proos et al. [16] aimed to compare dif-
ferences in knowledge as a result of a SAP compared to a
structured teaching programme. Patients in both groups
had higher scores in all knowledge test categories at dis-
charge compared to entry, however, statistically significant
differences between the groups were only found in the
categories of name, purpose, time to take and side effects
for SAP compared to structured teaching participants.
Some controlled studies seem to indicate that patients’
knowledge improves with time irrespective of whether
they participate in a SAP [37, 39], although control pa-
tients in one [35] received discharge counselling and the
number of controls in another [39] was small. In all the
studies data had been pooled for analysis and so the level
of patient’s pre-existing knowledge could not be taken into
account.
Do SAPs improve patient’s satisfaction with their care?
Measuring satisfaction with healthcare is difficult, partic-
ularly when views are determined whilst the patient is in
hospital or requires further care, as this may bias their
response. Seventeen papers [23, 25, 29, 37, 39, 40, 45–55]
were selected for review that had undertaken some measure
of patient satisfaction. Five were controlled studies [25, 37,
39, 45, 55]. All used a questionnaire or structured inter-
view; one was an informal survey [48]. One study [46]
used a mixture of multiple choice and open questions, four
used questions requiring yes/no/indifferent answers
[40, 45, 47, 52], three used Likert rating scales [25, 52, 54],
two, [39, 51] used open questions and Deeks and Byatt [55]
used a variety of questioning methods. Details of questions
were not provided in seven of the seventeen papers [23, 29,
37, 48, 49, 50, 53]. Five studies were postal surveys [40,
45, 47, 51, 55]. Those using multiple choice or yes/no/
indifferent answers had higher response rates [40, 47] than
those using open or mixed questions [51, 55]. High num-
bers of patients who had experienced SAPs responded in
favour of self-administration compared to nurse-adminis-
tration: 76–100% [23, 39, 40, 46, 49, 50]. Similarly when
Pharm World Sci (2006) 28:140–151 147
123
patients were asked whether they would choose to self-
administer in future if offered a choice, many of those who
had experienced a SAP answered in favour; 81–100% [37,
52, 55]. Only 20% of controls in the Leadbeater [37] study
said they would choose self-administration and all five
control patients in the Furlong study [39] preferred nurse
administration in the belief that it was more convenient for
the nurse and saved time, although, 9 patients in the study
group said they preferred self-administration because it
saved nursing time. The results from only two studies [25,
55] were statistically analysed. Jensen [25] reported 73.7%
of patients in both study and control groups preferred self-
administration and the self-administration group scored
significantly higher for understanding their medication and
coping on discharge, compared to admission. Deeks and
Byatt [55] reported a statistically different response
depending on control patients’ age; 45% of younger pa-
tients ( < 60 years of age) would choose self-administration
compared to 18% of older patients (>60 years). They also
found self-administering patients reported a significantly
better overall impression of their care (P < 0.05) and were
significantly more satisfied on their feeling on discharge
compared to controls (P = 0.008) The reasons why patients
were included or excluded from self-administration are
unclear, thus the control group could contain a dispropor-
tionate number of patients who would be unsuitable for
self-administration; this could explain why there were
more elderly patients in the control group. Work by Tho-
mas [70] also supports the perceptions of patients in the
control groups of the papers reviewed i.e. that approxi-
mately 80% of patients would prefer nurse-administration
if offered a choice.
Most patients who have experienced a SAP will be
satisfied with their experience and would chose this again,
but the majority of patients who have never experienced
self-administration are more likely to choose nurse
administration.
What resources are needed to implement and maintain
SAPs?
No studies were found which measured the overall impact
on resources of implementing a SAP. Several studies at-
tempted to measure the impact on pharmacy and nursing
time, but most of the data quoted are anecdotal, and lack
detail of methodology or tasks being undertaken. It is
difficult to measure time accurately when staff are subject
to constant interruptions, unless independent observers are
used. Furthermore, the validity of detailed time and motion
studies for individual staff groups could be questioned,
since it is the overall impact that is important as tasks
within a SAP could be undertaken by a variety of profes-
sionals.
No studies assessed an overall impact on time. Seven
papers [17, 56–61] contained some evaluation of pharmacy
time. Four lacked details of methodology. The amount of
time required by pharmacy staff is heavily influenced by
programme design. Figures given ranged from 15 min for
uncomplicated discharge counselling [17] to up to an hour
for complicated consultations [17, 58] or to start a typical
elderly patient on a full programme [59]. Johnson et al.
[56] suggested that a rehabilitation ward required 4–5 h of
pharmacist time daily if the pharmacist was responsible for
monitoring compliance and dispensing medication. Beau-
mont et al. [60] suggested that 105 min of technician time
and 90 min of pharmacist time per week was required for
dispensing a seven level programme for rehabilitation pa-
tients, but the report lacks details. Pearce [61] reported the
pharmacist required 10 min per patient at ward level with
an additional 10.4 min per patient for dispensing a mean
number of 5.6 medications per patient. It should be noted
that all papers reported figures before introduction of Pa-
tients’ Own Drug Schemes, which are now routine practice
in most UK hospitals. The amount of time required to
dispense one month’s supply of medication for patients
will be accounted for in the implementation of these
schemes. In most cases this will be offset by the cost saved
by not having to dispense inpatient supplies or by using
patients’ own medication [71–74]. No studies were found
that compared the amount of pharmacy time spent before
programme implementation with that required to set-up,
and maintain it.
Three papers [49, 60, 62] were reviewed which had
attempted some evaluation of nursing time, although
methodology was not described. It is suspected that two of
these papers [60, 62], are describing the same programme.
Although more nursing time was needed in early levels,
time was saved on later ones, but it is unclear whether
timings quoted are based on empirical data. Anderson and
Poole [49] reported 15 min instruction per patient was
required to start patients on a single level post-partum
obstetric programme and the amount of time spent on
medication rounds did not decrease.
Do SAPs result in fewer treatment failures, drug related
admissions or improve health outcomes?
No studies were found that measured the effect of SAPs on
treatment failures, drug related admissions or health out-
comes.
148 Pharm World Sci (2006) 28:140–151
123
Conclusion
Although SAPs have been reported in the literature for
many years and appear to be based on sound ideology and
commonsense, the vast majority of research is descriptive
and anecdotal. There is a paucity of well-designed studies
using sound methodologies. Most of the studies reviewed
had serious methodological flaws. Some were quasi-
experimental based on single sites, limiting generalisabil-
ity. Many used too small a sample size or had low response
rates, and little or no attempt was made to establish the
impact that non-responders or dropouts might have on the
findings. In most of the studies evaluation was undertaken
by practitioners providing the service, there was poor
control for investigator or observational bias.
The rationale for SAPs is based on the belief that im-
proved patient education leads to improved knowledge per
se and this will, in turn, improve concordance. Research has
shown that patients feel they receive insufficient informa-
tion about their medicines [75], in particular side effects
[76], and that providing patients with information improves
knowledge and satisfaction [77]. However, enhancing
knowledge does not necessarily improve compliance with
medication regimens. There are studies that demonstrate a
positive correlation between knowledge and compliance
and others that fail to find an association [78]. This may be
because medication knowledge is not a unitary concept, but
comprises different knowledge components. Clearly, fac-
tors that govern compliance are complex and varied. The
results from the studies reviewed failed to provide conclu-
sive evidence that SAPs improve compliance.
It is evident from the studies reviewed that patients do
make errors when participating in SAPs and the number of
errors may be higher than those made by other health
professionals when administering medicines. The impact of
these errors is not reported. There is insufficient evidence
to judge whether patients who have participated in a SAP
make fewer errors on discharge than those who have not
participated in a programme.
It is now widely accepted that the traditional concept of
compliance contains many questionable assumptions such
as that the patient is a passive, unquestioning recipient of
advice. It assumes that any problems with compliance are
associated with the patient alone [79]. The modern ap-
proach of achieving concordance means the patient is an
active participant in treatment decisions. On this basis it is
not possible to have a non-concordant patient; only a
consultation or a discussion between the two parties con-
cerned can be non-concordant [80]. The provision of
information, therefore, is important in achieving concor-
dance. Information can influence positively either directly,
e.g. how to take a medicine, or indirectly, e.g. correcting a
misunderstanding. However, information e.g. on risks of
treatment may have a negative influence [81]. Once con-
cordance is achieved, the issue of adherence to the agreed
regimen is an important goal that the SAP should support.
Most SAPs included information provision to patients,
most commonly as verbal explanations or counselling.
Some provided written information varying in format and
type. Studies lacked full descriptions of information pro-
vided making assessment difficult. Although most studies
seem to suggest that SAPs contribute positively to
increasing knowledge, it is not clear whether it is the
informational component of the programmes or the self-
administration component, or the combination of the two
that has the most importance.
Research suggests that patients who have taken part in
programmes feel they have benefited from them and would
take part again. The importance of giving patients a choice
is central to current UK government health policy. No
studies have measured the total resource requirement of
implementing and maintaining a SAP. Many of the claimed
advantages of SAPs are not substantiated by good scientific
research. The proportion of patients eligible for a SAP have
been reported as between 10 and 50% [27, 31, 47, 56] for
rehabilitation and as few as 26% [61] for cardiology,
suggesting that traditional methods of administration are
required for many patients.
There appears to be three theoretical reasons for estab-
lishing a SAP:
1. Diagnostic—to see whether a patient can cope with
self-administration before discharge.
2. Educational—to teach a patient how to self-administer
accurately before discharge.
3. Empowerment—to maintain a patient’s independence
and ability to self-care.
Some SAPs have been established without clearly de-
fined, or with inappropriate, goals. These may vary
depending on the clinical setting and differ between pa-
tients. To achieve concordance the patient’s view must be
given primacy in setting goals. Measuring how many pa-
tients achieve adherence to the regimen that should lead to
their desired goals could be used to evaluate the effec-
tiveness of a programme. It may, however, be more
important to identify patients not achieving desired thera-
peutic outcomes and considering strategies to remove
barriers that are preventing this. Health services are con-
tinually evolving and interventions are frequently intro-
duced to address perceived problems in the way in which
services are delivered. As many of these are based on
common sense or political ideology with little supporting
research evidence, there is potential for significant oppor-
tunity costs should the intervention be inefficient or inef-
fective. Well-designed research studies are needed to
Pharm World Sci (2006) 28:140–151 149
123
evaluate changes in practice retrospectively as well as
prospectively, to ensure that the desired objectives are
being met. In the case of SAPs further research is required,
in particular, to answer the following questions: Do SAPs
improve concordance in patients who are known to be poor
compliers? Do SAPs enable patients to learn more about
their medicines than an educational programme? What are
the total resources required to implement and maintain a
SAP in a modern day setting?
Acknowledgements The authors thank Dr. David Brown Ports-
mouth University for his valuable help in drafting this manuscript.
References
1. Parnell MA. Medicines at the bedside. Am J Nurs 1959; 59:1417–
1418.
2. UKCC. Standards for the Administration of medicines. UKCC
for Nursing Midwifery and Health Visitors; 1992.
3. Blom-Cooper L. Report of the committee of inquiry into com-
plaints about Ashworth Hospital. London: HMSO; 1992.
4. Pharmacy in the Future-implementing the NHS Plan. London:
Department of Health; 2000.
5. Implementing medicines related aspects of the NSF for Older
People. London: Department of Health; 2001.
6. Audit Commission. A spoonful of sugar-medicines management
in NHS hospitals. London: Audit Commission; 2001.
7. Audit Commission. Self-administration of medicines by hospital
inpatients; 2002. http://www.audit.commission.gov.uk/itc/doc/
self-admin.doc.
8. Hospital Pharmacists group. One-stop dispensing, use of patients’
own drugs and self-administration schemes. Hosp Pharm 2002;
9(3):81–86.
9. Ansar S, Silverthorne J. Patients’ own drugs and self-adminis-
tration of medication schemes in the unit. Int J Pharm Prac 2002;
10(Suppl.):R31.
10. Medicines Management in NHS Hospitals. Self-assessment per-
formance framework; 2003. http://www.doh.gov.uk/hospitalm-
edsmanframework.
11. The Society of Hospital Pharmacists of Australia Committee of
Specialty Practice in Rehabilitation. SHPA self-medication
guidelines. Aust J Hosp Pharm 1994; 24:416–417.
12. The Society of Hospital Pharmacists of Australia Committee of
Specialty Practice in Rehabilitation and Aged Care. SHPA
guidelines for self-administration of medication in hospitals and
residential care facilities. J Pharm Prac Res 2002; 32(4):324–325.
13. Bird C, Hassall J. Self administration of drugs – a guide to
implementation. Scutari Press; 1993.
14. NHS Plan. London: Department of Health; 2000.
15. Milton Keynes Primary Care Trust. Critical Appraisal Skills
Programme (CASP). Making sense of the evidence: 10 questions
to help you make sense of randomised controlled trials, reviews
and qualitative research; 2002.
16. Proos M, Reiley P, Eagan J, Strengrevics S, Castile J, Arian D. A
study of the effects of self-medication on patients’ knowledge of
and compliance with their medication. J Nurs Care Quart (special
report) 1992; 18–26.
17. Cole P, Emmanual Sister. Drug consultation: its significance to
the discharged hospital patient and its relevance as a role for the
pharmacist. Am J Hosp Pharm 1971; 28:954–960.
18. D’Altroy LH, Blissenbach HF, Lutz D. Patient drug administra-
tion improves regimen compliance. Hospitals 1978; 52:
131–136.
19. Beardsley RS, Anderson Johnson C, Kabat HF. A drug self-
administration program; a behavioural approach to patient edu-
cation. Contemp Pharm Prac 1982; 5:156–160.
20. Bird CA. Prescription for self-help. Nurs Times 1990;
86(43):52–55.
21. Wood SI, Calvert RT, Acomb C, Kay EA. A self medication
scheme for elderly patients improves compliance with their
medicines. Int J Pharm Prac 1992; 1(4):240–241.
22. Foster H, McLean KA, Giles R, Franklin G, Auckland J, Neal
KR, Austin CA. Self-medication does not improve drug com-
pliance. Proceedings of spring meeting of British Geriatric
Society 1993. Age Ageing 1993; 22(Suppl 3):23 [Abstract].
23. Lowe C, Raynor DK, Courtney EA, Purvis J, Teale C. Effects of
self-medication programme on knowledge of drugs and compli-
ance with treatment in elderly patients. BMJ 1995; 310:1229–
1231.
24. Day RA, Moore KN. Evaluation of a self-medication program:
pilot project. Can J Rehabil 1992; 5(4):205–216.
25. Jensen L. Self-administered cardiac medication program evalu-
ation. Can J Cardiovasc Nurs 2003; 13(2):35–44.
26. Carter F. Assessment of self-medication by elderly patients.
World Ir Nurs 1999; 7(2):18–19.
27. Hannay DG. Self-medication: a developing concept in future
hospital pharmacy service. Hosp Adm Can 1977; 19:33–37.
28. Wandless I, Davie JW. Can drug compliance in the elderly be
improved? BMJ 1977; 1:359–361.
29. Reibel EM. Study to determine feasibility of self-medication
program for patients at a rehabilitation centre. Nurs Res 1969;
18:65–68.
30. Libow LS, Mehl B. Self-administration of medications in hospital
or extended care facilities. J Am Geriatr Soc 1970; 18:81–85.
31. Roberts CJ, Miller WA. Clinical pharmacy, self-administration
and technician drug administration services in a 72-bed hospital.
Drug Intell Clin Pharm 1972; 6:408–415.
32. Davidson JR. Trial of self-medication in the elderly. Nurs Times
1974; 70(11):391.
33. Newcomer DR, Anderson RW. Effectiveness of a combined drug
self-administration and patient teaching program. Drug Intell Clin
Pharm 1974; 8:374–381.
34. Shannon M. Clinical forum nine: self-medication in the elderly.
Nurs Mirror 1983; 157(Suppl):i–viii.
35. Pereles L, Romonko L, Murzyn T, Hogan D, Silvius J, Stokes E,
Long S, Fung T. Evaluation of a selfmedication program. J Am
Geriatr Soc 1996; 44:161–165.
36. Bream S. Teaching the elderly about drugs. Nurs Times 1985;
81(29):32–34.
37. Leadbeater M. Increasing knowledge. Nurs Times 1991;
87(30):32–35.
38. Barry K. Patient self-medication: an innovative approach to
medication teaching. J Nurs Care Qual 1993; 8(1):75–82.
39. Furlong S. Do programmes of medicine self-administration fur-
ther patient knowledge, compliance and satisfaction? J Adv Nurs
1966; 23(6):1254–1262.
40. Hoffman RP, Kerchner J, Osburn C, St.Louis P, Stewart H. Self-
medication program for obstetric patients. Hosp Pharm 1978;
13:127–136.
41. Pelletier RD. Self-medication promotes patient independence in
rehabilitative setting. Hosp Pharm 1983; 18(2):96.
42. Thomas SG, Diethelm AG, Keith TD, Simmons SM. Evaluating
the quality of patient education in a selfmedication teaching
program. Hosp Formul 1983; 18:871–891.
43. Ng T, Shalansky F, Ustad T. Understanding psychiatric medi-
cations – development of a multicomponent education program.
Can J Hosp Pharm 1996; 49(2):80–84.
44. Noy K. A self-medication scheme in a post-coronary care unit. Br
J Nurs 1997; 6(7):369–374.
150 Pharm World Sci (2006) 28:140–151
123
45. Traiger GL, Bui LL. A self-medication administration program
for transplant recipients. Crit Care Nurse 1997; 17(1):71–79.
46. Buchanan EC, Brooks MR, Greenwood RB. A self-medication
program for cardiology inpatients. Am J Hosp Pharm 1972;
29(11):928–934.
47. Stonnington HH, Loehnen E, Miller PJ, Bloom J. Self-medication
in a rehabilitation unit: follow-up study. Hosp Formul 1977;
12:401–402.
48. Mynick A. Instituting a postpartum self-medication program.
MCN 1981; 6:422–424.
49. Anderson K, Poole C. Self-administered medications on a post-
partum unit. Am J Nurs 1983; 83(8):1178–1180.
50. Bornstein C. Self-medication program for rehabilitation patients.
Can J Hosp Pharm 1984; 37(2):63–65.
51. Kallas J. Establishing a self-administered medication program. J
Nurs Adm 1984; 14(11):38–42.
52. Jankowski H, Wells SM. Self-administered medications for
obstetric patients. MCN 1987; 12:199–203.
53. Ptashnick MB. Pharmaceutical care provides positive outcomes
for post-partum patients. Hosp Pharm 1995; 30(4):292–294.
54. Sutherland K, Semple S. Self-administration of drugs: an intro-
duction. Nurs Times 1995; 91(23):29–31.
55. Deeks PA, Byatt K. Are patients who self-administer their
medicines in hospital more satisfied with their care? J Adv Nurs
2000; 31(2):395–400.
56. Johnson E, Roberts CJ, Godwin HN. Self-medication for a
rehabilitation ward. Arch Phys Med Rehabil 1997; 51:300–303.
57. Lucarotti RL, Prisco HM, Hafner PE, Shoup LK. Pharmacist co-
ordinated self-administration medication program on an obstetric
service. Am J Hosp Pharm 1973; 30:147–150.
58. Taylor MD, Hajek VE. Self-medication on a rehabilitation unit.
Arch Phys Med Rehabil 1984; 6:612–613.
59. Walker C, Martin P. Self-medication for the elderly inpatient. Br
J Pharm Pract 1987; 9:47–52.
60. Beaumont B, Leblanc Y, Jaouich R. Self help. Can Pharm J 1991;
124:186–187.
61. Pearce M. Pilot study of self-medication: pharmacy workload
appraisal. New Zealand Pharm 1991; 11:18–19.
62. Platts S. A self-medication pilot programme. Dimensions 1989;
66(8):33–35.
63. Collingsworth S, Gould D, Wainwright SP. Patient self-admin-
istration of medication: a review of the literature. Int J Nurs Stud
1997; 34(4):256–269.
64. Lugg S, Doolan B. An evaluation of a self-administration pro-
gramme for patients within a high security hospital. Psychiatr
Care 1997; 4(5):225–228.
65. Horne R. Representations of medication and treatment: advances
in theory and measurement. In: Petrie KJ, Weinman JA, editors.
Perceptions of health & illness. Harwood Academic Publishers;
1997. pp. 155–188.
66. Parkin DM, Henney CR, Quirk J, Crooks J. Deviation from
prescribed drug treatment after discharge from hospital. BMJ
1976; 2:686–688.
67. Sackett DL. Methods for compliance research. In: Haynes RB,
Taylor DW, Sackett DL, editors. Compliance in health care.
Baltimore and London: The John Hopkins University Press;
1979. pp. 323–333.
68. Gordis L. Conceptual and methodological problems in measuring
patient compliance. In: Haynes RB, Taylor DW, Sackett DL,
editors. Compliance in health care. Baltimore and London: The
John Hopkins University Press; 1979. pp. 23–45.
69. Grimshaw J, Wilson B, Campbell M, Eccles M, Ramsay C.
Epidemiological methods. In: Fullop N, Allen P, Clarke A, Black
N, editors. Studying the organisation and delivery of health ser-
vices. Research methods. London and New York: Routledge
Publishers; 2001. pp. 56–72.
70. Thomas E. Self-medication. Nursing 1992; 12(6):316–319.
71. Dua S. Establishment and audit of a patients’ own drug scheme.
Hosp Pharm 2000; 7:196–198.
72. Campbell D, Cantrell, Conroy C. Waste not, want not. Health
Serv J 2000 (August); 24:31.
73. Reynolds N, Bali S. Setting up a near patient dispensing scheme.
Hosp Pharm 1999; 6(8):240–243.
74. Semple JS, Morgan JE, Garner ST, Sutherland K, Milligan M.
The effect of self-medication and re-use of patient’s own drugs
on a hospital pharmacy. Pharm J 1995; 255:124–126.
75. Ridout S, Waters WE, George CF. Knowledge of and attitudes to
medicines in the Southampton community. Br J Clin Pharmacol
1986; 21:701–712.
76. Ali A, Horne R. A survey of hospital inpatients’ satisfaction with
medicines. Information received and attitudes to medicines in
general. Pharm Prac 1996; 6:333–338.
77. Gibbs S, Waters WE, George CF. Prescription information leaf-
lets: a national survey. J R Soc Med 1990; 83:292–297.
78. Horne R. Adherence to medication: a review of existing research.
In: Myers L, Midence K, editors. Adherence to treatment in
medical conditions. London: Harwood Academic Publishers;
1998. pp. 285–310.
79. Noble LM. Doctor–patient communication and adherence to
treatment. In: Myers L, Midence K, editors. Adherence to treat-
ment in medical conditions. London: Harwood Academic Pub-
lishers; 1998. pp. 51–83.
80. Weiss M, Britten N. What is Concordance? Pharm J 2003;
271:493.
81. Raynor DK. The influence of written information on patient
knowledge and adherence to treatment. In: Myers L, Midence K,
editors. Adherence to treatment in medical conditions. London:
Harwood Academic Publishers; 1998. pp. 83–111.
Pharm World Sci (2006) 28:140–151 151
123