Secondary Dispensing – Still an Issue in Care


This is an issue that I came across recently whilst delivering training in medicines management to a domiciliary care.  I was surprised to hear how much it still happens out there and feel that it’s an area that needs to be highlighted and discussed – put out in the open if you like.

What is secondary dispensing?

Let me give you an example.

You have service users who visit a day centre and will be there for there lunch time medication. The medication is dispensed by the pharmacy into a monitored dosage system which you feel is a bit big for the service user to take to the day care centre with him or her so you take out the lunch time doses and put them into an envelope with their name on it for him/her to take with them.


You have a service user who goes home occasionally for the weekend. You don’t want to send the whole cassette with their medication in with them, perhaps you’re not sure it will be returned when they come back, so you put the weekend medication in to another container with their name on it and brief instructions as to when they should be taken.

What’s wrong with that you might say?

The issue is that you are not qualified to dispense medication. You are giving out medicines that are not labelled properly or legally and the medication is not identifiable in any way. It also does not give the service user proper dose instructions or warning instructions or safe storage instructions. By giving someone medication in this way you are taking responsibility for it, if some thing goes wrong you are liable because you acted outside of the law.

So that’s all very well you say – but what is the solution? How do you ensure that the service user gets the medication at the day centre or during home visits?

There are two possible solutions. The first is to send the service user with the medication in the original pack, be that the boxes and bottles dispensed by the pharmacy or the monitored dosage box (e.g. nomad tray, blister pack, dosette).
If your policies do not allow this to happen at present, then in order to operate with in the law perhaps it is time to review those policies.

The second option is to speak with the GP practice and the pharmacy to arrange to have the doses needed for outside your care dispensed in to separate containers that the service user can take with them. The medication must be dispensed by either a pharmacy or a dispensing doctor though, not by your staff.

But we’ve been doing this for years you cry! Yes…I know but it doesn’t make it right.

But our inspectors have never said anything about it you tell me……yes…..but perhaps as knowledgeable as they are they are in legislation and guidelines they are not experts in medicines and do not know that what you’re doing is not legal. When something goes wrong ignorance will not be a defence so better to put things right as soon as possible rather than hoe it will be ok and continue to break the law.

For further information or any questions about this or any other medication issues please contact



12 Responses to “Secondary Dispensing – Still an Issue in Care”

  1. Simon Says:

    I am looking to update the policy of meds in the service where I work. Please could you clarify the situation of care staff using medication pots to transfer meds from nomad trays to a client. I have been told that this can be seen as secondary dispensing, as the client might decide not to take the meds from the pot once dispensed. Is this true, and would this also mean they are breaking the law?

    Sorry, the last email I sent had a misspelling in the email address…Simon

  2. teejay648 Says:

    Hi Simon,

    To clarify your situation medicines must be given to or prompted from the original container (the container that it arrived in from the pharmacy) any thing else is secondary dispensing no matter how briefly the medication is in another container or why so in your case you are most definitely secondary dispensing and you can be prosecuted for it.
    Solution – keep the medication in the original container and obtain consent from the service user before removing medication from the packaging so that if refused the medication remains in the container and the information is recorded on the MAR chart – and your staff stay within the law 🙂

    If I can be of further assistance please let me know.

    Best regards


  3. Heartburn Home Remedy Says:

    Not that I’m impressed a lot, but this is more than I expected for when I stumpled upon a link on SU telling that the info is quite decent. Thanks.

  4. Zapo Says:

    Thanks for valuable info and clarification on the matter.

    I’m looking for the actual law or regulation that covers this?

    Could you help?


  5. Tracey Dowe Says:

    Here’s some further information and guidance that you might find useful

    pharmacy tips – secondary dispensing CQC

    Leave medication

    Copy and paste the links into your browser

    Best regards


  6. Zapo Says:

    Many thanks for quick reply.
    Very, very useful.

  7. g. griffiths Says:

    has secondary dispensing got the same meaning as secondary administration. e.g. in a care home?

  8. g. griffiths Says:

    what is secondary administration?

  9. Tracey Dowe Says:

    Secondary dispensing is the same as secondary administration. Technically the correct term is secondary dispensing but often in care the two words are misued.

    Dispensing is what a pharmacist does in preparing and labeling and puttuing the medication into it’s container.
    When you take it out of the 1st container that the pharmacy put the medication into and put it into a second container – that is secondary dispensng.

    Administration is the act of supporting someone to take their medicationbu prompting, assisting or physically giving or applying medication for that person.

    So you can secondary dispense but it would be difficlt to seconday administer. AND niether is ethical!

    Unfortunately still too often in all care environments care staff and nurses are secondary dispensing – leaving themseves and their clients VERY vulnerable and at risk of erros AND at risk of prosecution for doing so.

    I hope that helped to give some clarity for you.

    Best Regards


  10. liz Ellis Says:

    I am a trainer and deliver medication training to staff.
    I have been informed that the rules on secondary dispensing have been relaxed!!!
    Is this true and if so can you let me know what the rules/guidelines state now.
    Many thanks

  11. Tracey Bell Says:

    Whereby i accept what is being said with regard to secondary dispensing – how do care workers get around this without the scaremongering? How do you gain consent from adults without capcity and with profound learning disabilites? Have you got a good example as to how this can be managed and written up in policies? Surely, every care worker and Nurse in the land are practicing illegally. This does not appease our staff who need to be trained and reassured in medication management and its systems.

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