Standards › Standard 29 › Standard operating procedures (SOPs)
Procedure · HC-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 29.18
At a glance
- A medicine change, hospital discharge, new prescriber or change of caregiver triggers a full review of the regimen (LTC-SOP-002).
- A missed or uncertain dose is followed up the same day and recorded (29.20).
- The shared medication list is updated at each change (HC-FRM-008).
- A new medicine is not left off the home list.
- Stop and get help straight away if: a hospital discharge has a new drug that is not added to the home list.
1. Purpose
To make sure medicine changes and missed doses are actively managed (29.18, 29.20).
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
The most dangerous moments for medicines are changes: a hospital discharge, a new prescriber, a change of dose. Reconciling the list at those points catches the error.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for home care | Owns the review rule | Clinician |
| Caregiver or nurse | Reports changes and missed doses | Staff |
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 change.
- Review the full regimen at each change or transition, and update HC-FRM-008.
Key point: Reviewed.
Step 2. Follow up missed doses.
- Follow up any missed or uncertain dose the same day, and record it.
Key point: Followed up.
Step 3. Close the loop.
- Confirm the list and the client’s supply agree.
Key point: Confirmed.
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 |
|---|---|---|---|---|
| Medicine changes reviewed with the shared list updated | 100% | Monthly | Clinical lead for home care | 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 |
|---|---|---|
| HC-FRM-008 | Shared medication list | Record |
| LTC-FRM-002 | Medicine reconciliation form (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global strategy and action plan on ageing and health 2016-2030, WHO Integrated care for older people (ICOPE) guidelines (2017), and WHO guidance on migrant health. |
| 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)