Standards › Standard 17 › Standard operating procedures (SOPs)
Procedure · PHA-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 17.7
At a glance
- Count stock each month and check expiry dates.
- Order to a set level, to avoid both shortage and wastage.
- For a shortage, follow the process: notify, source, or substitute with pharmacist approval.
- Remove expired stock at once and record the removal on PHA-REG-004.
- Stop and get help straight away if: a common medicine is out of stock with no process followed.
1. Purpose
To keep stock available to patients, without shortage or wastage from expiry (17.7).
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
Running out of a medicine harms patients, and holding too much wastes money and leads to expiry. A managed stock, with a defined process for ordering, prevents both.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Pharmacist in charge | Owns the stock rule and approves substitutions | Pharmacist |
| Dispensing staff | Count, check expiry and report shortages | 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. Count and check.
- Count stock and check expiry dates each month (PHA-REG-004).
Key point: Counted.
Step 2. Order and act on shortage.
- Order to the set level. For a shortage, notify, source, or substitute with pharmacist approval.
Key point: Shortage handled.
Step 3. Remove expired stock.
- Remove expired stock at once and record it.
Key point: Removed and recorded.
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 |
|---|---|---|---|---|
| Monthly stock counts with expiry checked | 100% | Monthly | Pharmacist in charge | 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 |
|---|---|---|
| PHA-REG-004 | Stock and expiry register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Medication Without Harm guidance (2017) and the WHO Good storage and distribution practices (2010). |
| 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)