Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-007 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.7
At a glance
- Compare the patient’s own medicines with the hospital list at admission, transfer and discharge.
- Resolve every discrepancy with the prescriber.
- Record each decision and its reason.
- Give the discharge list to the patient.
- Stop and get help straight away if: a discrepancy is found and no prescriber decision is recorded.
1. Purpose
To stop medicines being missed, duplicated or stopped by mistake when a patient moves (S1.7).
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 |
|---|---|---|
| Admitting nurse or pharmacist | Takes the list; compares; records the discrepancies | Trained |
| Prescriber | Decides on each discrepancy | Doctor |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Medicines reconciliation form (HOS-FRM-006) | Current | Available at each point |
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. Take the list.
- Ask for the patient’s own medicines, including those from home and pharmacy.
Key point: Ask for the bottles or packs if possible.
Step 2. Compare.
- Compare with the hospital chart line by line.
Key point: Each line needs a decision.
Step 3. Resolve.
- Ask the prescriber to decide on each discrepancy.
- Record the decision and the reason.
Key point: The decision is the reconciliation.
Step 4. Hand over.
- Give the patient the discharge list at discharge.
Key point: The patient is the last 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 |
|---|---|---|---|---|
| Episodes with reconciliation at each point | At least 70% | Monthly | Chief pharmacist | Escalate to clinical director |
| Discrepancies with a prescriber decision | 100% | Monthly | Chief pharmacist | Escalate to clinical director |
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-006 | Medicines reconciliation form | Form |
| HOS-SOP-010 | Discharge and aftercare planning | Discharge list |
17. Evidence
| Reference | Note |
|---|---|
| E-007 | WHO Nine patient safety solutions (2007). |
| 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)