Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-016 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.22
At a glance
- When the system is down, slow or wrong, switch to the paper route at once.
- Use the paper prescription and dispensing form.
- Make the checks the software normally makes, by hand.
- Enter the paper records into the system when it is back, and check them.
- Stop and get help straight away if: prescribing or dispensing continues with no paper route and no checks.
1. Purpose
To keep medicines safe when the electronic system is not working (S1.22). The checks the software normally makes must still happen.
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
When the software fails, medicines still need to be safe. A written downtime procedure, tested, keeps high-alert medicines checked by hand.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Duty manager | Declares the downtime and tells staff | Senior manager |
| Chief pharmacist | Owns the paper route and its checks | Pharmacist |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Downtime prescription and dispensing form (HOS-FRM-014) | Current | In each area |
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. Declare.
- The duty manager declares the downtime and tells the wards and pharmacy.
Key point: Everyone switches at once.
Step 2. Prescribe on paper.
- Use HOS-FRM-014.
- Check allergies, weight, renal function and interactions by hand.
Key point: The software checks are now yours.
Step 3. Dispense and check.
- Check each item against the paper prescription.
- Record the check on the form.
Key point: Two signatures for high-alert items.
Step 4. Return to the system.
- Enter the paper records when the system is back.
- Check the entries against the paper.
Key point: Nothing is left unentered.
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 |
|---|---|---|---|---|
| Downtime events with paper route used | 100% | Each event | Chief pharmacist | Escalate to chief executive |
| Drills of the paper route in the last 12 months | 100% | Yearly | 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-014 | Downtime prescription and dispensing form | Form |
| HOS-REG-004 | Rehearsal and drill record | Drill record |
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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