Standards › Standard S1 › Policies
Policy · HOS-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criteria S1.5, S1.6, S1.7
At a glance
- Medicines are stored, controlled, checked and reconciled under this policy.
- Controlled drugs are locked and counted each shift.
- High-alert medicines have a second check.
- Medicines reconciliation happens at admission, transfer and discharge.
- Stop and get help straight away if: a medicine is given without a prescription or a controlled drug count does not match.
1. Purpose
To set one set of rules for medicines in the hospital: storage, controlled drugs, high-alert medicines and reconciliation (S1.5 to S1.7). Medicine harm is a priority area of the WHO Medication Without Harm challenge.
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A patient’s own medicines are often changed or missed at admission and discharge. A reconciliation at each change is the safest way to catch this.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief executive | Approves the policy and receives the annual report | Executive |
| Chief pharmacist | Owns the policy and the stock rules | Pharmacist |
| Ward manager | Makes sure the rules are followed on the ward | Nurse manager |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Store.
- Follow HOS-SOP-005 for temperature and locking.
Key point: Storage is the first barrier.
Step 2. Control.
- Follow HOS-REG-001 for controlled drugs.
Key point: Counts are checked each shift.
Step 3. Protect against high-alert harm.
- Follow HOS-SOP-006 for high-alert medicines.
Key point: Two checks for high-risk doses.
Step 4. Reconcile.
- Follow HOS-SOP-007 at each transfer point.
Key point: Reconcile before the list is used.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Controlled drug counts matching the register | 100% | Each shift | Ward pharmacist | Escalate to chief pharmacist |
| High-alert doses with second check | 100% | Monthly | Chief pharmacist | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HOS-SOP-005 | Medicine storage and temperature control | Storage |
| HOS-SOP-006 | High-alert medicines | High-alert rules |
| HOS-SOP-007 | Medicines reconciliation | Reconciliation |
17. Evidence
| Reference | Note |
|---|---|
| E-007 | WHO Nine patient safety solutions (2007). |
| E-009 | Medication Without Harm, WHO 2017 (third global patient safety challenge). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
- World Health Organization (2007). Nine patient safety solutions, including correct patient identification. Geneva: WHO. Open source (E-007)