Standards › Standard 51 › Standard operating procedures (SOPs)
SOP · ONC-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 51.2
At a glance
- Every chemotherapy dose, drug, route and infusion rate is checked by two qualified people (ONC-FRM-002).
- Each checker forms their own judgement and does not sign on the other’s check alone.
- The check covers the patient’s identity, the protocol, the dose, the route and the rate.
- A mismatch stops the administration until it is resolved.
- Stop and get help straight away if: a chemotherapy dose is given without two independent checks recorded.
1. Purpose
To make sure every chemotherapy dose is verified independently by two qualified people before it is given (51.2).
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
Chemotherapy doses are high and mistakes are severe. An independent second check by a second trained person catches the error before it reaches the patient.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Oncology pharmacist | Verifies the protocol and the first check | Clinical lead |
| Second qualified checker | Carries out an independent second check | Oncology 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. First check.
- The first qualified person checks the dose, drug, route and rate against the protocol.
Key point: Checked.
Step 2. Second check.
- A second qualified person checks independently, without relying on the first.
Key point: Confirmed.
Step 3. Record or stop.
- Record both checks (ONC-FRM-002). Stop and resolve any mismatch before giving the dose.
Key point: Recorded.
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 |
|---|---|---|---|---|
| Doses with two recorded independent checks | 100% | Monthly | Oncology pharmacist | Stop the administration |
| Mismatches resolved before administration | 100% | Monthly | Oncology pharmacist | Review the process |
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 |
|---|---|---|
| ONC-FRM-002 | Chemotherapy two-person check record | Record |
| HOS-FRM-005 | High-alert second-check record (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| 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)