Standards › Standard 29 › Standard operating procedures (SOPs)
Procedure · HC-SOP-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 29.19
At a glance
- Medicines belonging to each person are stored separately and labelled with the owner’s name.
- Medicines are checked against the owner before each administration.
- A controlled medicine is stored securely and recorded (PHM-FRM-002).
- Any medicine given to the wrong person is reported at once.
- Stop and get help straight away if: a husband’s heart tablets are given to his wife.
1. Purpose
To prevent one household member taking another’s medicine (29.19).
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
Medicines for different people in the same home can be mixed up, especially by an aide who is not familiar with the household. Storing each person’s medicines separately prevents that.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for home care | Owns the storage rule | Clinician |
| Caregiver | Checks owner and medicine before each task | 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. Separate and label.
- Store each person’s medicines separately, labelled with the owner’s name.
Key point: Separated.
Step 2. Check before giving.
- Check the owner and the medicine before each administration.
Key point: Checked.
Step 3. Report errors.
- Report any medicine given to the wrong person at once under INC-POL-001.
Key point: Reported.
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 |
|---|---|---|---|---|
| Households with medicines separated and labelled | 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 |
|---|---|---|
| PHM-FRM-002 | Controlled medicines register (existing, reused) | Register |
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)