Standards › Standard 41 › Policies
Policy · TRM-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 41.4
At a glance
- Each product has a known and licensed source (PHA-REG-003).
- Each product is labelled with its ingredients and warnings (TRM-REG-002).
- No product is presented with an unlicensed claim.
- Products from an unknown source are not supplied.
- Stop and get help straight away if: a product with an unknown source or no label is supplied to a patient.
1. Purpose
To make sure products supplied to patients are safe, traceable and honestly described (41.4).
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
Products used or sold in traditional and complementary practice can contain undeclared drugs, heavy metals or allergens. Knowing the source and reading the label protects patients.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Service lead | Owns the sourcing and labelling standard | Clinical director |
| Product buyer | Buys only from licensed sources and checks labels | Service lead |
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. Source.
- Buy only from licensed sources on the register (PHA-REG-003).
Key point: Sourced.
Step 2. Label.
- Check each product label for ingredients and warnings (TRM-REG-002).
Key point: Labelled.
Step 3. Check claims.
- Check each product and its advertising for unlicensed claims.
Key point: Checked.
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 |
|---|---|---|---|---|
| Products with source and label checked | 100% | Quarterly | Service lead | Escalate to the 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 |
|---|---|---|
| TRM-REG-002 | Product sourcing and labelling register | Register |
| PHA-REG-003 | Licensed supplier and batch source register (existing) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Traditional Medicine Strategy 2014–2023, the WHO guidance on substandard and falsified medical products, and the ASF Hospital standard for informed consent and incident reporting. |
| 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)