Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.5
At a glance
- Store each medicine at the temperature on its label.
- Read and record fridge and room temperatures every day.
- Act on every out-of-range reading the same day.
- Remove expired and recalled stock at once.
- Stop and get help straight away if: a medicine has been stored out of range and is still being given.
1. Purpose
To keep medicines at the correct temperature, secure and in date (S1.5).
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
Medicines lose potency or are misused when storage fails. Temperature and controlled-medicine records are cheap to keep and show control.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Ward pharmacist or nurse | Reads and records temperatures; removes expired stock | Trained in cold chain |
| Chief pharmacist | Reviews the logs and the recalls | Pharmacist |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Calibrated thermometer or logger in each fridge and room | Calibrated yearly | Checked monthly |
| Expiry and recall log | Current | Updated weekly |
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. Read.
- Read and record the temperature each day, at the same time.
Key point: A missed reading is a failure of the check.
Step 2. Act on out of range.
- Move the stock to a working store.
- Tell the pharmacist the same day.
- Do not give out-of-range stock until the pharmacist decides.
Key point: Out of range is not automatically lost; the pharmacist decides.
Step 3. Check expiry and recalls.
- Check the expiry dates and the recall notices each week.
- Remove expired and recalled stock to the quarantine area.
Key point: Quarantine keeps it out of use.
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 |
|---|---|---|---|---|
| Daily readings recorded | 100% | Weekly | Chief pharmacist | Escalate to chief executive |
| Out-of-range readings with action | 100% | Each reading | Ward pharmacist | Escalate to chief pharmacist |
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-POL-001 | Medicines management policy | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Storage limits from the product label and the national medicines standard. |
| 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)