Standards › Standard 58 › Standard operating procedures (SOPs)
SOP · WRD-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 58.2
At a glance
- Medicines are checked against the chart before each dose, with a second check for each high-alert medicine (HOS-SOP-006).
- Each omitted or refused dose is recorded with the reason (WRD-REG-001).
- Medicines are reconciled at admission, transfer and discharge (HOS-SOP-007).
- Stop and get help straight away if: a high-alert medicine is given without the second check, or a dose is omitted without a recorded reason.
1. Purpose
To make sure medicines reach the right patient, in the right dose, and any omission is explained (58.2).
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
To make sure medicines reach the right patient, in the right dose, and any omission is explained (58.2).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Ward nurse | Checks the chart and records each dose or omission | Ward lead nurse |
| Ward doctor | Reconciles medicines at admission, transfer and discharge | Clinical lead |
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 the chart before each dose, and the second check for each high-alert medicine.
Key point: Checked.
Step 2. Give or omit.
- Give the dose, or record the omission or refusal with the reason (WRD-REG-001).
Key point: Given.
Step 3. Reconcile.
- Reconcile medicines at admission, transfer and discharge (HOS-FRM-006).
Key point: Reconciled.
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 |
|---|---|---|---|---|
| High-alert doses with a second check recorded | 100% | Monthly | Ward lead nurse | Review the dose with the prescriber |
| Omitted or refused doses with a reason | 100% | Monthly | Ward lead nurse | Review the chart |
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 |
|---|---|---|
| WRD-REG-001 | Medicine administration and omission register | Register |
| HOS-SOP-006 | High-alert medicines (existing, reused) | SOP |
17. Evidence
| Reference | Note |
|---|---|
| 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)