Standards › Standard S1 › Policies
Policy · HOS-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.15
At a glance
- Every dispensed item is checked against the prescription.
- A qualified pharmacist is accountable whenever the hospital is open.
- Record every dispensing error and review it.
- Use the paper route if the system is down.
- Stop and get help straight away if: the pharmacy is open with no accountable pharmacist.
1. Purpose
To make dispensing accurate and accountable at all hours (S1.15).
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
Dispensing errors reach patients when no one checks against the prescription. A named accountable pharmacist and recorded errors make the service safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief pharmacist | Owns the policy and the rota | Pharmacist |
| Dispensing pharmacist | Checks and signs each item | Pharmacist |
| Dispensing technician | Prepares items under the pharmacist check | Trained |
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. Check.
- Check each item against the prescription, the patient and the dose.
- Record the check (HOS-FRM-009).
Key point: The check is recorded.
Step 2. Record errors.
- Record every error with the cause.
- Review the error log monthly.
Key point: Errors are learning.
Step 3. Cover the hours.
- Keep a named accountable pharmacist on the rota for every opening period.
Key point: No open period without a pharmacist.
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 |
|---|---|---|---|---|
| Items with recorded check | 100% | Monthly | Chief pharmacist | Escalate to chief executive |
| Opening periods with an accountable pharmacist | 100% | Monthly | Chief pharmacist | Escalate to chief executive |
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 |
|---|---|---|
| HOS-FRM-009 | Dispensing check record | Record |
| HOS-FRM-014 | Downtime prescription and dispensing form | Paper route |
17. Evidence
| Reference | Note |
|---|---|
| E-007 | WHO Nine patient safety solutions (2007). |
| E-009 | Medication Without Harm (WHO 2017). |
| 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 |
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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)
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