Standards › Standard 9 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · FLD-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 9.12
At a glance
- Each donated item is checked for source, expiry, storage condition and approval before use.
- An item that fails any check is withheld, labelled and recorded.
- A withheld item is not used, and is returned or destroyed as the rule requires.
- The check is recorded on FLD-FRM-005.
- Stop and get help straight away if: a donated medicine or item is used before it has been checked, or one that failed a check is used.
1. Purpose
To stop expired, unapproved or badly stored donations reaching patients (9.12).
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
Donated medicines and equipment often arrive with unknown history, expired stock and wrong storage. Checking each item before use prevents harm from something that looked helpful.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Pharmacist or supply lead | Runs the check | Pharmacist |
| Field unit lead | Withholds and approves disposal | Clinician |
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. Check each item.
- Check source, expiry, storage condition and approval for each donated item (FLD-FRM-005).
Key point: Every item, every time.
Step 2. Withhold a failure.
- Label and withhold an item that fails any check, and record it.
Key point: Failed means withheld.
Step 3. Dispose.
- Return or destroy withheld items as the rule requires, and record the disposal.
Key point: No failed item left in 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 |
|---|---|---|---|---|
| Donated items checked before use | 100% | Monthly | Pharmacist or supply lead | Escalate to field unit lead |
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 |
|---|---|---|
| FLD-FRM-005 | Donation check record | Record |
| PRC-FRM-001 | Supplier review record (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on WHO classification and minimum standards for emergency medical teams (2013). |
| 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)