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PRN Medication Management Policy

1. Purpose

The purpose of this policy is to ensure that all PRN medicines, also known as “as required” medicines, are prescribed, obtained, stored, administered, recorded, monitored, reviewed and disposed of safely within {{org_field_name}}.

PRN medicines must only be used where there is a clear clinical reason, where the medicine is prescribed or lawfully authorised, and where its use is consistent with the individual’s assessed needs, personal plan, medication administration record, PRN protocol and, where relevant, best-interest decision-making under the Mental Capacity Act 2005.

This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, the Welsh Government statutory guidance for care home and domiciliary support services, CIW inspection expectations, the Social Services and Well-being (Wales) Act 2014, the Mental Capacity Act 2005, the Human Rights Act 1998, safeguarding duties, and recognised national medicines-management guidance.

PRN medicines must be managed in a way that promotes the individual’s safety, dignity, independence, rights, well-being and personal outcomes.

2. Scope

This policy applies to all staff involved in the management of PRN medicines within {{org_field_name}}, including registered nurses, care staff, senior care staff, managers, agency staff, and any staff who support individuals with medicines under the organisation’s medication procedures.

This policy applies to all PRN medicines, including but not limited to:

• prescribed PRN medicines;
• PRN controlled drugs;
• PRN medicines used for pain, constipation, nausea, anxiety, agitation, breathlessness, epilepsy rescue treatment, allergy symptoms, sleep, end-of-life care or behavioural distress;
• topical PRN preparations such as creams, ointments and gels;
• inhalers, eye drops, ear drops, nasal sprays and patches used on a PRN basis;
• PRN medicines supplied in original packs, monitored dosage systems or separate containers;
• anticipatory medicines used for end-of-life care;
• PRN medicines administered covertly, where this has been lawfully authorised;
• PRN medicines self-administered by the individual, where this has been assessed as safe.

This policy must be read alongside the main Medication Management and Administration Policy, Safeguarding Adults from Abuse and Improper Treatment Policy, Mental Capacity and Deprivation of Liberty Safeguards Policy, Positive Behaviour Support or Behaviour Management Policy, Incident Reporting Policy, Record Keeping Policy, and any local health board, GP, pharmacy or prescriber instructions relevant to the individual.

3. Principles of PRN Medication Management

{{org_field_name}} is committed to the following key principles:

• Safe Administration: PRN medication is given in line with prescribing instructions and only when necessary.
• Person-Centred Approach: Medication is administered with respect for the individual’s preferences and assessed needs.
• Regular Review: PRN medication use is regularly reviewed to ensure effectiveness and prevent overuse.
• Clear Documentation: All administrations, refusals, and effects of PRN medication are clearly recorded.
• Staff Training: All staff involved in PRN medication management receive appropriate training.

PRN medication must not be used for staff convenience, to compensate for insufficient staffing, as a substitute for person-centred care, or as a routine intervention where the medicine is prescribed only for occasional or specific use.

PRN medicines must be administered in accordance with the individual’s prescription, MAR chart, PRN protocol, personal plan, known preferences, communication needs and any relevant risk assessments.

The least restrictive and most person-centred option must always be considered. Where PRN medication is used to support distress, anxiety, agitation or behaviour that may challenge, staff must first consider whether the individual has pain, infection, constipation, hunger, thirst, tiredness, emotional distress, sensory needs, environmental triggers or unmet communication needs.

The individual must be supported to be involved in decisions about PRN medicines wherever possible. Information must be provided in a way the individual can understand, taking account of language, communication needs, capacity, cognition, sensory impairment and preferred method of communication.

4. PRN Protocols

A PRN medicine must not be administered unless there is a clear PRN protocol in place, except in an urgent situation where a healthcare professional gives specific instructions and this is recorded clearly.

Each PRN protocol must be person-centred and must include:

• the individual’s name;
• the name, strength, form and route of the medicine;
• the condition, symptom or presentation the medicine is prescribed for;
• how the individual may communicate or show that the medicine may be needed, including non-verbal signs;
• known triggers or circumstances that may lead to the need for PRN medication;
• non-pharmacological interventions to be considered before administration, where appropriate;
• the exact dose to be given;
• where a variable dose is prescribed, the circumstances in which each dose should be given;
• the minimum time interval between doses;
• the maximum dose in 24 hours;
• whether the medicine may cause drowsiness, falls risk, constipation, breathing difficulties, bleeding risk or other side effects requiring monitoring;
• what observations or monitoring are required after administration;
• the expected effect and the expected timescale for effect;
• what action staff must take if the medicine is ineffective;
• when staff must seek advice from the GP, pharmacist, prescriber, NHS 111 Wales, community nurse, mental health team, emergency services or other relevant professional;
• any restrictions, cautions, allergies or contraindications;
• whether the medicine is a controlled drug;
• arrangements for review and discontinuation if the medicine is no longer required.

The PRN protocol must be available with the MAR chart and must be reflected in the individual’s personal plan. Staff must read the PRN protocol before administering the medicine.

PRN protocols must be reviewed at least monthly internally, whenever the medicine is used frequently, whenever the individual’s needs change, after any medicine-related incident, following hospital discharge, following a change in dose or directions, and as part of the individual’s medication review with the GP, pharmacist or prescriber.

5. Assessment and Decision-Making for PRN Medication

PRN medicines must only be used where they are prescribed or lawfully authorised by an appropriate healthcare professional and where clear directions are available.

Before administering PRN medication, staff must assess and record:

• the individual’s current symptoms or presentation;
• whether the symptoms match the indication stated on the prescription and PRN protocol;
• when the medicine was last administered;
• whether the minimum time interval has passed;
• whether the maximum dose in 24 hours would be exceeded;
• whether non-medicine interventions have been tried or considered, where appropriate;
• whether there are any changes in the individual’s condition that require professional advice before administration;
• whether the individual is able to consent to the medicine at that time.

Where the individual has capacity to decide about the PRN medicine, their decision must be respected, including a decision to refuse the medicine.

Where there is reason to believe the individual may lack capacity to decide about the PRN medicine at that time, staff must follow the Mental Capacity Act 2005. Any capacity assessment must be decision-specific and time-specific. Where the individual lacks capacity, any decision to administer PRN medication must be made in the individual’s best interests, must be the least restrictive option, and must be recorded clearly.

Family members, representatives or attorneys must not be asked to consent on behalf of the individual unless they have lawful authority to do so, such as a valid and applicable Lasting Power of Attorney for health and welfare, court-appointed deputyship or other legal authority.

Where PRN medication is considered for distress, agitation, anxiety or behaviour that may challenge, staff must consider unmet needs, environmental factors, pain, infection, constipation, communication difficulties and emotional distress before administration. PRN medication must not be used as a form of unlawful restraint or for staff convenience.

6. Administration of PRN Medication

Only staff who have completed medication training, have been assessed as competent, and have been authorised by {{org_field_name}} may administer PRN medication. Registered nurses remain professionally accountable for nursing decisions and any delegated medicines activity within their scope of practice.

Before administering PRN medication, staff must check:

• the right individual;
• the right medicine;
• the right dose;
• the right route;
• the right time;
• the right documentation;
• the prescription and MAR chart;
• the PRN protocol;
• allergies and contraindications;
• the expiry date and condition of the medicine;
• whether the medicine has already been administered;
• whether the minimum interval between doses has passed;
• whether the maximum dose in 24 hours would be exceeded;
• whether there are any signs of adverse reaction, deterioration or clinical concern.

Where the medicine is prescribed as a variable dose, staff must follow the PRN protocol and record the reason why the selected dose was given. Staff must not guess the dose. If the directions are unclear, the medicine must not be administered until advice has been obtained from the prescriber, pharmacist, GP, out-of-hours service or other appropriate healthcare professional.

PRN medicines must be administered in a person-centred, dignified and respectful way. Staff must explain the medicine to the individual, support the individual to make an informed decision where possible, and respect their wishes unless a lawful best-interest process applies.

The following must be recorded on the MAR chart and/or PRN record immediately after administration:

• date and time of administration;
• name, strength and form of the medicine;
• dose administered;
• route of administration;
• reason for administration;
• symptoms or presentation observed;
• non-medicine interventions tried or considered, where appropriate;
• staff member’s signature or electronic identifier;
• running balance, where required, including for controlled drugs;
• effect of the medicine and time reviewed;
• any side effects or adverse reaction;
• any escalation or professional advice sought.

The effect of PRN medication must be monitored and recorded within the timescale stated in the PRN protocol. Where no timescale is specified, staff must use professional judgement and the nature of the medicine to ensure timely monitoring. If the medicine is ineffective, if symptoms worsen, or if there are concerns about side effects, staff must escalate to the nurse in charge, senior staff member, GP, pharmacist, NHS 111 Wales, emergency services or other relevant professional as appropriate.

7. Medicines Reconciliation and Changes to PRN Medication

PRN medicines must be included in medicines reconciliation when an individual is admitted to the service, returns from hospital, attends outpatient appointments, changes GP, changes pharmacy, or has a medication review.

The service must ensure that PRN medicines listed on the MAR chart match the current prescription, discharge summary, GP instructions, pharmacy label and personal plan. Any discrepancy must be queried immediately with the prescriber or pharmacist and must be recorded.

When a PRN medicine is started, stopped, changed or discontinued, the MAR chart, PRN protocol, personal plan and stock records must be updated promptly. Staff must be informed of the change before they next administer or support the medicine.

Handwritten amendments to MAR charts must only be made in line with the organisation’s medication policy and must be checked and signed by authorised staff. Where possible, confirmation from the prescriber or supplying pharmacy must be obtained.

8. Monitoring and Review of PRN Medication

The use of PRN medication must be monitored to ensure it remains necessary, effective and safe. Staff must record the outcome after each administration, including whether the medicine achieved the intended effect and whether any side effects occurred.

PRN medication must be reviewed:

• at least monthly by the manager, nurse or nominated competent person as part of internal medication monitoring;
• during the individual’s personal plan review;
• whenever the PRN medicine is used frequently or not used at all;
• after any medication error, near miss, adverse reaction, fall, safeguarding concern or hospital admission;
• when the individual’s condition changes;
• when the prescriber, GP, pharmacist or multidisciplinary team requests a review;
• at formal medication review, at least annually or more often where clinically indicated.

Where PRN medication is used repeatedly, staff must escalate this to the GP, pharmacist, prescriber or relevant healthcare professional. Frequent use may indicate uncontrolled symptoms, pain, anxiety, constipation, infection, deterioration, mental health need, environmental distress or a need to change the care plan or prescribed treatment.

Where PRN medication has not been used for a prolonged period, the service must ask the prescriber or pharmacist to review whether it remains clinically required.

Medication reviews must consider whether the PRN medicine remains appropriate, whether the dose and instructions are clear, whether side effects are occurring, whether the medicine should be continued, changed or stopped, and whether non-medicine support or alternative treatment is required.

9. Storage, Security, Stock Control and Disposal of PRN Medication

PRN medication must be stored safely and securely in accordance with the organisation’s Medication Management and Administration Policy, the medicine’s storage requirements, the manufacturer’s instructions, the pharmacy label, and applicable legal requirements.

PRN medicines must be stored in a locked medicine cupboard, trolley, refrigerator or controlled drugs cabinet as appropriate. Medicines requiring refrigeration must be stored within the required temperature range and fridge temperatures must be monitored and recorded in accordance with the main medication policy.

PRN controlled drugs must be stored, recorded, administered and disposed of in accordance with controlled drug requirements and the organisation’s controlled drug procedure. Running balances must be maintained and checked regularly.

PRN medication must remain identifiable and must not be removed from its original container unless this is part of a lawful and safe dispensing or administration system. Labels must be clear, legible and current. Staff must not administer PRN medication where the label is unclear, the medicine is expired, the medicine appears damaged or contaminated, or the directions are ambiguous.

Stock levels must be monitored to ensure PRN medicines are available when needed and to prevent unnecessary overstocking. Ordering and re-ordering must be timely and must take account of the individual’s current use, expiry dates, clinical need and review arrangements.

Expired, discontinued, refused, contaminated or no longer required PRN medicines must be disposed of safely in accordance with the organisation’s disposal procedure and pharmacy arrangements. Disposal records must be maintained, including for controlled drugs where applicable.

10. Refusal of PRN Medication

Individuals with capacity have the right to refuse PRN medication. Staff must respect the individual’s decision and must not pressure, mislead or coerce the individual into taking medication.

Where an individual refuses PRN medication, staff must record:

• the date and time of the refusal;
• the medicine refused;
• the reason for refusal, if known;
• the symptoms or circumstances at the time;
• advice or reassurance offered;
• any alternative support provided;
• whether the refusal created a risk to the individual or others;
• whether escalation was required.

If refusal of PRN medication may place the individual or others at risk of harm, staff must escalate the matter promptly to the nurse in charge, senior staff member, manager, GP, pharmacist, prescriber, mental health team, NHS 111 Wales or emergency services as appropriate.

Where there is concern that the individual lacks capacity to decide about the medicine at that time, staff must follow the Mental Capacity Act 2005. Any best-interest decision must be recorded and must involve appropriate professionals and representatives where required.

PRN medication must not be administered covertly following refusal unless there is a lawful covert medication decision in place.

11. Covert Administration of PRN Medication

Covert administration means giving medication in a disguised form without the individual knowing at the time it is being given. Covert administration is only permitted where the individual lacks capacity to consent to the specific medicine, where administration is necessary and in the individual’s best interests, and where all legal and best-practice requirements have been followed.

PRN medication must not be administered covertly unless:

• a decision-specific mental capacity assessment has been completed;
• a best-interest decision has been made and recorded;
• the GP, prescriber or pharmacist has confirmed that the medicine can be safely given covertly;
• the method of covert administration is clearly recorded;
• less restrictive options have been considered;
• the decision has involved relevant people, such as family, representatives, attorneys, advocates and healthcare professionals, where appropriate;
• the covert administration plan is recorded in the personal plan, medication records and PRN protocol;
• the arrangement is reviewed regularly and whenever circumstances change.

Covert PRN medication must never be used for staff convenience or as a way of overriding a capacitous refusal.

12. PRN Medication for Distress, Anxiety, Agitation or Behavioural Support

PRN medication used for distress, anxiety, agitation or behaviour that may challenge must be used only where there is a clear clinical rationale, a lawful prescription, a person-centred PRN protocol and clear guidance within the individual’s personal plan.

Staff must consider and record possible causes of distress before administering PRN medication, including pain, infection, constipation, hunger, thirst, tiredness, sensory overload, environmental noise, emotional distress, fear, communication difficulties, boredom, loneliness or changes in routine.

Non-pharmacological interventions must be considered first where safe and appropriate. These may include reassurance, de-escalation, quiet space, meaningful activity, sensory support, communication support, repositioning, pain assessment, hydration, toileting support, family contact or involvement of staff who know the individual well.

PRN medication must not be used as punishment, restraint, sedation for convenience, or as a substitute for adequate staffing, positive behaviour support or clinical review.

Where PRN medication has a sedating effect or restricts the individual’s liberty of movement, staff must consider whether this amounts to chemical restraint. Any use must be necessary, proportionate, in the individual’s best interests where they lack capacity, and consistent with the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and the organisation’s policy on control, restraint and restrictive practice.

Any repeated use of PRN medication for behaviour or distress must trigger a review of the individual’s personal plan, PRN protocol, risk assessment and behaviour support plan, involving the GP, pharmacist, mental health team, learning disability team or other relevant professionals as appropriate.

13. Self-Administration of PRN Medication

Individuals must be supported to manage their own PRN medication where this is safe, appropriate and consistent with their wishes, capacity and assessed needs.

Before an individual self-administers PRN medication, a risk assessment must be completed and recorded. The assessment must consider:

• the individual’s capacity and understanding of the medicine;
• whether the individual knows when and how to take the medicine;
• whether the individual understands the dose, timing and maximum daily dose;
• whether the medicine can be stored safely;
• risks to the individual or others;
• whether the individual needs reminders, monitoring or support;
• how use will be recorded;
• how stock levels and expiry dates will be checked;
• when the arrangement will be reviewed.

Where an individual self-administers PRN medication, the personal plan must state the agreed arrangements, including what support staff will provide and what records must be kept.

14. Staff Training and Competency

Staff must not administer, support or monitor PRN medication unless they have completed appropriate medication training, understand this policy and the main Medication Management and Administration Policy, and have been assessed as competent.

Training and competency must include:

• safe administration of PRN medicines;
• reading and following MAR charts and PRN protocols;
• the 6 rights of medication administration;
• person-centred decision-making;
• consent, refusal and mental capacity;
• best-interest decisions;
• covert medication;
• controlled drugs;
• variable-dose PRN medicines;
• monitoring effectiveness and side effects;
• record keeping;
• escalation of concerns;
• medicine-related incidents, errors and near misses;
• safeguarding concerns linked to medication;
• storage, stock control and disposal;
• delegated healthcare tasks where applicable.

Competency must be assessed before staff administer PRN medicines independently and must be reviewed at least annually, following any medication error or concern, following a change in role, following a period of absence where competence may be affected, and whenever the manager identifies a need for reassessment.

Agency staff must receive a local induction before administering PRN medication. This must include access to the medication policy, PRN protocols, MAR charts, escalation arrangements and reporting procedures.

15. Compliance, Audit and Governance

The manager, nurse in charge or nominated competent person must ensure that PRN medication systems are audited regularly. PRN medication audits must include:

• whether each PRN medicine has a current PRN protocol;
• whether the MAR chart and PRN protocol match the prescription;
• whether the reason for administration is recorded;
• whether the dose, route, time and staff signature are recorded;
• whether the effect of the medicine is recorded;
• whether maximum doses and minimum intervals are followed;
• whether stock balances are accurate;
• whether controlled drug records are accurate, where applicable;
• whether medicines are stored correctly;
• whether expiry dates are checked;
• whether discontinued medicines are removed and disposed of safely;
• whether frequent or unusual PRN use has been escalated;
• whether refusals are recorded and managed appropriately;
• whether covert PRN medication decisions are lawful and current;
• whether staff administering PRN medication are trained and competent.

Medication audits must be completed at least monthly and more frequently where risks, errors, incidents or concerns are identified.

Medication errors, near misses, adverse reactions, unexplained stock discrepancies, missing signatures, administration outside prescribed directions, or concerns about overuse or misuse of PRN medication must be reported through the organisation’s incident reporting procedure. Where required, the manager must notify the GP, pharmacist, prescriber, safeguarding team, CIW, local authority, health board, police or other relevant body.

Learning from audits, incidents, complaints, safeguarding concerns and professional advice must be used to improve practice. Actions taken must be recorded and monitored to completion.

16. Medicine-Related Incidents, Errors and Safeguarding

All medication errors, near misses, adverse effects and medicine-related concerns must be reported promptly in accordance with the Incident Reporting Policy and Safeguarding Adults from Abuse and Improper Treatment Policy.

Examples of medicine-related concerns include:

• PRN medication given without a valid prescription or protocol;
• PRN medication given for the wrong reason;
• PRN medication given too frequently;
• maximum dose exceeded;
• medication given to the wrong individual;
• medication given by the wrong route;
• medication omitted when clinically required;
• refusal not acted upon where risk is present;
• covert administration without lawful authorisation;
• unexplained stock loss or discrepancy;
• suspected misuse, diversion or theft of medication;
• repeated use of PRN medication to sedate or control an individual;
• failure to seek medical advice when PRN medication is ineffective.

The manager must review all medicine-related incidents and ensure that immediate action is taken to protect individuals. This may include seeking medical advice, informing the individual and/or representative where appropriate, raising a safeguarding referral, notifying CIW where required, reviewing staff competence, increasing audits, changing procedures or arranging further training.

Where an incident has caused harm, may have caused harm, or indicates abuse, neglect or improper treatment, safeguarding procedures must be followed without delay.

17. Anticipatory and End-of-Life PRN Medication

Where anticipatory or end-of-life PRN medicines are prescribed, staff must follow the individual’s prescription, MAR chart, PRN protocol, end-of-life care plan and instructions from the GP, community nursing team, palliative care team or other relevant healthcare professional.

Anticipatory medicines must be stored securely and must be available when required. Staff must understand who is authorised to administer them and when professional support must be requested.

The use of anticipatory PRN medicines must be recorded clearly, including the reason for administration, dose, time, route, effect and any advice received from healthcare professionals.

The individual’s wishes, advance statements, advance decisions, DNACPR documentation, family involvement and spiritual, cultural or religious needs must be respected and reflected in the personal plan where applicable.

18. Transfers, Hospital Admissions and External Appointments

When an individual transfers to hospital, another care setting, respite care or an external appointment, accurate information about PRN medication must be shared with the receiving service or healthcare professional.

Information shared must include:

• current PRN medicines;
• dose, route, frequency and maximum dose;
• reason for use;
• time and dose last administered;
• known effectiveness;
• side effects or concerns;
• allergies;
• covert medication arrangements, where applicable;
• controlled drug information, where applicable.

When the individual returns to the service, staff must complete medicines reconciliation and confirm whether any PRN medicines have been started, stopped, changed or discontinued.

19. Related Policies and Procedures

This policy must be read in conjunction with:

• CHW11 – Safe Care and Treatment Policy
• CHW21 – Medication Management and Administration Policy
• CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CHW39 – Mental Capacity and Deprivation of Liberty Safeguards Policy
• Incident Reporting Policy
• Record Keeping and Confidentiality Policy
• Positive Behaviour Support / Behaviour Management Policy
• Control, Restraint and Restrictive Practice Policy
• End-of-Life Care Policy
• Infection Prevention and Control Policy
• Staff Training and Competency Policy
• Complaints Policy
• Whistleblowing Policy
• Data Protection and Confidentiality Policy

20. Policy Review

This policy will be reviewed at least annually or sooner if there are changes in legislation, Welsh Government statutory guidance, CIW requirements, NICE guidance, safeguarding procedures, local health board guidance, pharmacy arrangements, organisational practice, audit findings, incidents, complaints or identified risks.

The Registered Manager is responsible for ensuring that this policy remains current and is implemented in practice. The Responsible Individual must maintain oversight of medication governance, including PRN medication audit outcomes, significant incidents, safeguarding concerns and improvement actions.

Any changes to this policy must be communicated to relevant staff. Where changes affect staff practice, additional training, supervision or competency checks must be completed.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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