Standards › Standard 17 › Policies
Policy · PHA-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 17.3
At a glance
- A qualified pharmacist is accountable whenever the service is open, and the name is displayed.
- Cover is matched to opening hours and recorded on PHA-REG-001.
- The service does not open without an accountable pharmacist on duty.
- Any gap in cover is closed or the service is closed.
- Stop and get help straight away if: the pharmacy is open with no pharmacist on duty.
1. Purpose
To make sure a qualified pharmacist is accountable for every dispensing period (17.3).
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 pharmacy without a qualified pharmacist in charge has no one accountable for what is dispensed. Accountability must be named and present whenever the service is open.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Responsible pharmacist | Owns the cover rule and the rota | Pharmacist |
| Service manager | Opens the service only when cover is in place | Manager |
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. Name the pharmacist.
- Name the accountable pharmacist for each session on the rota (PHA-REG-001) and display the name.
Key point: Named and displayed.
Step 2. Match cover to hours.
- Match the rota to the opening hours, and record any gap.
Key point: Matched.
Step 3. Close if no cover.
- Do not open the service, or close it, if no pharmacist is on duty.
Key point: Closed if uncovered.
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 |
|---|---|---|---|---|
| Opening sessions with an accountable pharmacist on duty | 100% | Monthly | Responsible pharmacist | Escalate to medical 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 |
|---|---|---|
| PHA-REG-001 | Pharmacist rota and cover register | Register |
| WRK-REG-001 | Training matrix register (existing, reused) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Medication Without Harm guidance (2017) and the WHO Good storage and distribution practices (2010). |
| 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 |
E-learning for this document
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)