Positive Risk-Taking in Medication Management for Older People’s Services
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Medication management is one of the highest-risk areas in older people’s services, particularly where polypharmacy, cognitive impairment, frailty, and fluctuating capacity intersect. In response, services can default to restrictive controls such as removing independence entirely or avoiding shared decision-making. Positive risk-taking reframes medication support by balancing safety with autonomy, ensuring decisions are proportionate, documented, and regularly reviewed. This article sits within positive risk-taking and aligns closely with quality and governance, because medication enablement must be auditable, defensible, and consistently delivered.
Why over-restrictive medication practice creates hidden risk
Removing choice or independence in medication use can reduce immediate perceived risk, but it may increase longer-term harm. People may disengage, refuse medication, hide tablets, or lose understanding of what they are taking and why. This can lead to missed doses, duplication, adverse reactions, or avoidable hospital admission. Restriction can also undermine trust, particularly where people previously managed their own medicines.
Positive risk-taking does not mean unmanaged self-administration. It means assessing capability, identifying specific risks, and putting proportionate controls in place so people can remain involved in medication decisions at a level that is safe and meaningful.
Day-to-day controls that support safe enablement
Effective medication enablement is practical and consistent across shifts. It typically includes:
- Clear assessment of medication understanding, memory, dexterity, and insight.
- Defined levels of support (prompting, supervised self-administration, full administration).
- Consistent explanations of purpose and side effects in accessible language.
- Agreed escalation triggers (missed doses, refusal patterns, side effects).
- Regular review following changes in health, cognition, or medication regime.
These controls reduce variation between staff and support safe, repeatable practice.
Operational example 1: Supported self-administration with supervision
Context: A resident wanted to continue managing their own medication after moving into supported accommodation. Staff were concerned about memory lapses and dosage errors.
Support approach: The service completed a structured medication risk assessment and agreed a supervised self-administration model rather than removing independence entirely.
Day-to-day delivery detail: Medication was stored securely in a monitored cabinet. Staff prompted the person at agreed times and observed administration without taking control unless a risk trigger occurred. A simple checklist confirmed correct medication and dose. Any uncertainty triggered immediate support and review.
How effectiveness is evidenced: Medication audits showed full adherence, incident records showed no errors, and supervision notes evidenced staff confidence. The person reported increased trust and reduced anxiety.
Operational example 2: Managing refusal while respecting autonomy
Context: A person frequently refused medication, particularly during periods of low mood. Staff attempted repeated prompting, which escalated distress.
Support approach: The service reframed refusal as information rather than non-compliance and explored underlying triggers.
Day-to-day delivery detail: Staff agreed respectful language and limited prompts. Medication was reoffered later at preferred times, and side effects were reviewed with health professionals. Refusals were recorded with context rather than simply ticked as “not taken.”
How effectiveness is evidenced: Refusal frequency reduced, engagement improved, and GP reviews led to medication adjustments. Records demonstrated a clear rationale for decisions and timely review.
Operational example 3: Managing polypharmacy risk through shared review
Context: A resident was prescribed multiple medications, contributing to dizziness and falls risk.
Support approach: The service coordinated a structured medication review involving the person, GP, pharmacist, and care staff.
Day-to-day delivery detail: Staff recorded observed side effects and timing patterns. Information was shared clearly with health professionals, and the person was supported to express preferences and concerns. Changes were introduced gradually with close monitoring.
How effectiveness is evidenced: Falls reduced, alertness improved, and medication records showed clearer rationale and review history.
Commissioner expectation
Commissioners expect safe medication systems that reduce avoidable harm, support independence where appropriate, and demonstrate effective partnership with health professionals. They will look for evidence of structured review and outcome monitoring.
Regulator / Inspector expectation (CQC)
CQC expects medicines to be managed safely, with people involved in decisions about their care. Inspectors will look for least restrictive practice, accurate records, clear escalation, and staff who understand the reasons behind medication plans.
Governance and assurance mechanisms
Strong services evidence positive risk-taking through regular medication audits, competence checks, incident trend analysis, and supervision discussions that test understanding rather than compliance. Reviews following refusal, errors, or health changes should be clearly documented, with learning shared across the team.
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