Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.6
At a glance
- Use the hospital list of high-alert medicines.
- Every high-alert dose has an independent second check.
- Keep concentrated electrolytes and insulin apart from general stock.
- Label concentrated electrolytes as high-alert on every ward.
- Stop and get help straight away if: a high-alert dose is given without a second check.
1. Purpose
To prevent serious harm from medicines that carry a high risk when wrong (S1.6).
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 |
|---|---|
| High-alert medicine | A medicine that can cause serious harm when given in error, from the hospital list |
| Second check | An independent check of the dose, the drug and the patient by a second trained person |
4. Background
High-alert medicines cause serious harm when given wrongly. An extra independent check and separate storage prevent the most common errors.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Prescriber | Writes the dose clearly | Doctor |
| Nurse giving the dose | Asks for the second check; gives the dose | Trained |
| Second checker | Checks independently and records the check | Trained |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Hospital high-alert list | Current | Displayed on each ward |
| Separate storage for concentrated electrolytes and insulin | In place | Checked on the walk |
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. Identify.
- Check the medicine against the high-alert list.
Key point: If it is on the list, the second check applies.
Step 2. Second check.
- A second trained person checks the drug, the dose, the route and the patient.
- Both sign on the record.
Key point: The second check is independent, not a glance.
Step 3. Give and record.
- Give the dose.
- Record the check and the time.
Key point: No record, no check.
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 |
|---|---|---|---|---|
| High-alert doses with second check recorded | 100% | Monthly | Chief pharmacist | Escalate to chief executive |
| Separate storage in place | 100% | Monthly | 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-FRM-005 | High-alert second-check record | Record of each check |
| HOS-POL-001 | Medicines management policy | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-007 | WHO Nine patient safety solutions (2007). |
| E-009 | Hospital list to be set by the pharmacy and therapeutics committee. |
| 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)