Standards › Standard S1 › Forms
Form · HOS-FRM-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.6
Purpose
Records the independent second check for each high-alert dose.
How to complete
- Complete for every high-alert dose.
- Both the giver and the checker sign.
- Write any difference found and what was done.
Checks
| Check | Entry |
|---|---|
| High-alert medicine on the list | Yes |
| Second check by a trained person | Yes |
| Drug, dose, route and patient checked | Yes |
| Both signatures | Yes |
Evidence
| Reference | Note |
|---|---|
| E-007 | WHO Nine patient safety solutions (2007). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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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)
- World Health Organization (2007). Nine patient safety solutions, including correct patient identification. Geneva: WHO. Open source (E-007)