Standards › Standard 3 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · MNP-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 3.2
At a glance
- Review each opioid prescription at the set review date.
- Compare the amount given with the amount prescribed.
- Check the controlled drug register each month for patterns.
- Report any concern to the steward and the chief pharmacist the same day.
- Stop and get help straight away if: a concern about diversion is found and not reported the same day.
1. Purpose
To keep opioid prescribing under review and to find misuse early (3.2).
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
Opioids can relieve pain but they also cause harm when they are over-prescribed, given for too long, or not monitored. A stewardship approach keeps the dose and duration to what the patient needs.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Designated opioid steward | Runs the monthly review | Clinician |
| Pharmacist | Checks the register each month | Pharmacist |
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. Review.
- At the review date, record the pain score, the dose used and whether the opioid is still needed (MNP-FRM-001).
Key point: Need is checked, not assumed.
Step 2. Count.
- Compare the amount given with the amount prescribed, and check the controlled drug register.
Key point: Counts match.
Step 3. Report.
- Report any concern to the steward and the chief pharmacist the same day.
Key point: Same day.
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 |
|---|---|---|---|---|
| Monthly register checks done | 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 |
|---|---|---|
| MNP-FRM-001 | Opioid prescribing review record | Form |
| HOS-REG-001 | Controlled drugs register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022). |
| 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)