Standards › ASF Health Standards V11 › Standard 8
Standard 8 (Medicines Safety), PDF
ASF-HS11-S08 · 1 November 2026 · 27 pages, A4. The same criteria as this page, for printing and assessors.
Where this standard applies
Standard 8 is a core standard. It applies to every facility type except fitness and wellness, where it is marked N/A. The table shows each criterion by facility type.
| Criterion | Hospital | Ambulatory clinic | Primary health clinic | Long-term care | Telemedicine | Home care | Fitness and wellness | Dental clinic | Aesthetic and procedure clinic |
|---|---|---|---|---|---|---|---|---|---|
| 8.1 Look-Alike, Sound-Alike Medications Are Specifically Managed | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
| 8.2 Each Prescription Is Checked Before Dispensing | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
| 8.3 High-Alert Medicines Are Double-Checked Before Giving | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
| 8.4 Medicines Are Stored Securely and at the Right Temperature | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
| 8.5 Controlled Medicines Are Recorded and Counted | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
| 8.6 Medicines Are Reconciled at Admission, Transfer and Discharge | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
| 8.7 Medication Errors Are Reported and Reviewed | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
Medicines Safety
Medicines are managed safely, from look-alike and sound-alike medicines and prescription checks to high-alert medicines, storage, controlled medicines, reconciliation and error reporting. Pain criteria are in Standard 10 (Pain Management).
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
8.1
Look-Alike, Sound-Alike Medications Are Specifically Managed
Humanitarian settings: MediumTransition and fragile: MustStandard: Must
Medicines with names or packaging that could be confused with another are listed for the facility's own stock and managed with distinct safeguards: separated storage, distinct labelling or an independent check.
Rating: Medium in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. Two drugs that look or sound alike are a common cause of serious dispensing errors. A named list and distinct safeguards stop a mix-up before it reaches the patient.
Questions the surveyor asks
- Is there a named list of look-alike, sound-alike medicines for this facility's own stock? General awareness of the risk is not the same as a list for what the facility holds.
- Are these medicines stored apart or distinctly labelled? Physical or visual separation, not reliance on staff memory alone.
- Is there an extra check step for these medicines? An additional safeguard is needed beyond general dispensing practice.
How the surveyor verifies this criterion
Sample. The list, the storage areas and the dispensing records for 20 dispensed items from the last 3 months.
1. List exists and is current
Method. Check the list against the current stock list.
Evidence to show. Look-alike and sound-alike medicines list (MNP-REG-001).
Pass when. Every stocked look-alike, sound-alike medicine is on the list, and the list is reviewed at least yearly.
2. Separation or labelling in place
Method. Walk through the storage areas and check labels.
Evidence to show. Look-alike and sound-alike medicines policy (MNP-POL-001).
Pass when. Every listed medicine is stored apart or carries a distinct label.
3. Extra check is recorded
Method. Check the dispensing records for listed medicines.
Evidence to show. Dispensing check record (HOS-FRM-009).
Pass when. The extra check is recorded for every listed medicine dispensed in the sample.
Immediate fail (any one means the criterion is not met)
- No list exists for the facility's own stock.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. The list is current, listed medicines are stored apart, and an extra check is recorded for each one.
Partial because. The list exists but is not current, or the extra check is done but not recorded.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Prescriber (doctor) ISCO 2212 ASF proposal |
Writes and reviews prescriptions and high-alert orders. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
MNP-POL-001 |
| Pharmacist ISCO 2262 ASF proposal |
Checks, dispenses and counts medicines and keeps the records. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Care & Treatment: Clinical Standards for Accreditation (H-04, Georgian version only) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
MNP-REG-001 MNP-POL-001 HOS-FRM-009 |
| Nurse ISCO 2221 ASF proposal |
Gives medicines, checks them at the bedside and records each dose. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Care & Treatment: Clinical Standards for Accreditation (H-04, Georgian version only) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-FRM-009 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Medication Safety: Operating SOP-MED-01 End to End (T-08) GMJ Academy: English · Georgian |
Nurses and pharmacists | None |
| Care & Treatment: Clinical Standards for Accreditation (H-04, Georgian version only) GMJ Academy: Georgian |
Nurses and pharmacists | None |
| The Medication-Use Process (PS-10) GMJ Academy: English · Georgian |
None | Nurses and pharmacists |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| MNP-REG-001 · Look-alike and sound-alike medicines list Register · Lists each medicine on the look-alike and sound-alike list, with its safeguard and the date of the last review. |
Records officer (ISCO 4132) | Chief pharmacist (ISCO 2262) | Records officer (ISCO 4132) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| MNP-POL-001 · Look-alike and sound-alike medicines Policy · To prevent dispensing errors between medicines that look or sound alike. |
Chief pharmacist (ISCO 2262) | Chief executive (ISCO 1120) | Clinical lead (ISCO 1342) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HOS-FRM-009 · Dispensing check record Form (record) · Records the check of each dispensed item against the prescription. |
Nurse (ISCO 2221) | Clinical pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2007). WHO Nine Patient Safety Solutions. Used for: look-alike, sound-alike medication names (8.1). https://news.gmj.ge/guideline/who-nine-patient-safety-solutions-2007/
- World Health Organization (2017). Medication Without Harm: Global Patient Safety Challenge on Medication Safety. Used for: reducing avoidable harm from medicines (8.1). https://news.gmj.ge/guideline/medication-without-harm-global-patient-safety-challenge-on-medication-safety/
8.2
Each Prescription Is Checked Before Dispensing
Humanitarian settings: MustTransition and fragile: MustStandard: Must
Every prescription is checked by a qualified pharmacist before it is dispensed, for dose, route, allergies, interactions and the patient's identity, and the check is recorded.
Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. Most dispensing errors are caught at the point of checking. A check that is skipped or not recorded gives no protection.
Questions the surveyor asks
- Is every prescription checked before it leaves the pharmacy? Urgent and downtime supplies included.
- Does the check cover dose, route, allergies and interactions? A quick look at the drug name alone misses most errors.
- Is the check recorded? An unrecorded check cannot be audited.
How the surveyor verifies this criterion
Sample. Twenty dispensing records from the last 3 months, including at least five out-of-hours or downtime supplies.
1. Each prescription is checked
Method. Check each sampled record for a pharmacist check.
Evidence to show. Dispensing check record (HOS-FRM-009).
Pass when. The check is recorded for every sampled prescription.
2. The check covers the key items
Method. Check the record against the dose, route, allergy and interaction fields.
Evidence to show. Pharmacy dispensing policy (HOS-POL-002).
Pass when. All four items are recorded in every sampled record.
3. Counselling is given
Method. Check the counselling record for each sampled patient.
Evidence to show. Counselling record (PHA-FRM-001).
Pass when. Counselling is recorded for every sampled patient.
Immediate fail (any one means the criterion is not met)
- Medicines are dispensed with no pharmacist check at all.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Every prescription checked and recorded, with all key items covered and counselling recorded.
Partial because. The check is done but not recorded, or the key items are not covered.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Prescriber (doctor) ISCO 2212 ASF proposal |
Writes and reviews prescriptions and high-alert orders. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-POL-002 |
| Pharmacist ISCO 2262 ASF proposal |
Checks, dispenses and counts medicines and keeps the records. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) The Medication-Use Process (PS-10) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-FRM-009 HOS-POL-002 PHA-FRM-001 |
| Nurse ISCO 2221 ASF proposal |
Gives medicines, checks them at the bedside and records each dose. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) The Medication-Use Process (PS-10) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-FRM-009 PHA-FRM-001 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Medication Safety: Operating SOP-MED-01 End to End (T-08) GMJ Academy: English · Georgian |
Nurses and pharmacists | None |
| The Medication-Use Process (PS-10) GMJ Academy: English · Georgian |
Nurses and pharmacists | Prescribers |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HOS-FRM-009 · Dispensing check record Form (record) · Records the check of each dispensed item against the prescription. |
Nurse (ISCO 2221) | Clinical pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HOS-POL-002 · Pharmacy dispensing policy Policy · To make dispensing accurate and accountable at all hours. |
Chief pharmacist (ISCO 2262) | Chief executive (ISCO 1120) | Clinical lead (ISCO 1342) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| PHA-FRM-001 · Counselling record Form (record) · Records the counselling given on a new medicine, and whether the patient understood it. |
Nurse (ISCO 2221) | Clinical pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2017). Medication Without Harm: Global Patient Safety Challenge on Medication Safety. Used for: safe prescribing and dispensing (8.2). https://news.gmj.ge/guideline/medication-without-harm-global-patient-safety-challenge-on-medication-safety/
8.3
High-Alert Medicines Are Double-Checked Before Giving
Humanitarian settings: MediumTransition and fragile: MustStandard: Must
High-alert medicines, such as insulin, concentrated potassium, anticoagulants and opioids, are double-checked by a second qualified person before they are given, and the check is recorded.
Rating: Medium in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. A small error with a high-alert medicine can cause serious harm quickly. A second check catches what one person misses.
Questions the surveyor asks
- Is there a list of high-alert medicines used in the facility? The list must match what is actually stocked and given.
- Is a second qualified person involved in each check? The same person checking their own work does not count.
- Is the check recorded? A check that is not written down cannot be audited.
How the surveyor verifies this criterion
Sample. Twenty administrations of high-alert medicines from the last 3 months, and the high-alert medicines list.
1. List exists
Method. Check the list against the medicines stocked and given.
Evidence to show. High-alert medicines (HOS-SOP-006).
Pass when. Every high-alert medicine given in the sample is on the list.
2. Second check happens
Method. Check each sampled administration for a second signature.
Evidence to show. Ward medicine administration checks (WRD-SOP-002).
Pass when. A second qualified person checks at least 18 of the 20 sampled administrations.
3. Check is recorded
Method. Check the administration chart for each sampled dose.
Evidence to show. High-alert medicines on every ward (ONC-SOP-006).
Pass when. The second check is recorded for every sampled administration.
Immediate fail (any one means the criterion is not met)
- High-alert medicines are given without any second check.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. A list of high-alert medicines is kept, and each one is double-checked and recorded.
Partial because. The second check is done but not recorded, or only some of the list is covered.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Prescriber (doctor) ISCO 2212 ASF proposal |
Writes and reviews prescriptions and high-alert orders. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
— |
| Pharmacist ISCO 2262 ASF proposal |
Checks, dispenses and counts medicines and keeps the records. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) High-Alert Medication Safety (PS-03) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-SOP-006 WRD-SOP-002 ONC-SOP-006 |
| Nurse ISCO 2221 ASF proposal |
Gives medicines, checks them at the bedside and records each dose. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) High-Alert Medication Safety (PS-03) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-SOP-006 WRD-SOP-002 ONC-SOP-006 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Medication Safety: Operating SOP-MED-01 End to End (T-08) GMJ Academy: English · Georgian |
Nurses and pharmacists | None |
| High-Alert Medication Safety (PS-03) GMJ Academy: English · Georgian |
Nurses and pharmacists | Prescribers |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HOS-SOP-006 · High-alert medicines Procedure (SOP) · To prevent serious harm from medicines that carry a high risk when wrong. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| WRD-SOP-002 · Ward medicine administration checks Procedure (SOP) · To make sure medicines reach the right patient, in the right dose, and any omission is explained. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| ONC-SOP-006 · High-alert medicines on every ward Procedure (SOP) · To make sure that medicines with a high risk of serious harm when used in error are given with extra safeguards on every ward, and that these safeguards are recorded. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2017). Medication Without Harm: Global Patient Safety Challenge on Medication Safety. Used for: high-risk situations in the use of medicines (8.3). https://news.gmj.ge/guideline/medication-without-harm-global-patient-safety-challenge-on-medication-safety/
- World Health Organization (2007). WHO Nine Patient Safety Solutions. Used for: control of concentrated electrolyte solutions (8.3). https://news.gmj.ge/guideline/who-nine-patient-safety-solutions-2007/
8.4
Medicines Are Stored Securely and at the Right Temperature
Humanitarian settings: MediumTransition and fragile: MustStandard: Must
Medicines are kept in secure storage, at the temperature the manufacturer specifies, with temperature checked and recorded, and out-of-date stock removed.
Rating: Medium in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. Medicines that are stored too warm, too cold, or without security lose their effect or are misused. Regular checking catches the problem early.
Questions the surveyor asks
- Is storage secure and locked? Access is limited to authorised staff.
- Is the temperature checked and recorded every day? A recorded range is needed, not an occasional spot check.
- Is out-of-date stock removed? Expired medicines are quarantined and removed, not left on the shelf.
How the surveyor verifies this criterion
Sample. Storage areas and the temperature records for the last 30 days, plus the stock and expiry register.
1. Secure storage
Method. Inspect the storage area and the key log.
Evidence to show. Medicine storage and temperature control (HOS-SOP-005).
Pass when. Storage is locked, and access is limited to named staff.
2. Temperature recorded daily
Method. Check the temperature log for the last 30 days.
Evidence to show. Medicine storage and temperature monitoring (PHM-SOP-001).
Pass when. Temperature is recorded every working day, and out-of-range readings are acted on.
3. Stock is in date
Method. Check the stock and expiry register against the shelves.
Evidence to show. Stock management, shortages and expiry (PHA-SOP-002).
Pass when. No expired medicine is on the shelves, and expired stock is recorded as removed.
Immediate fail (any one means the criterion is not met)
- Medicines are kept unlocked and with no temperature records at all.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Secure storage, daily temperature records, and expired stock removed and recorded.
Partial because. Temperature is recorded but not on every day, or expiry checks are done but not recorded.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Prescriber (doctor) ISCO 2212 ASF proposal |
Writes and reviews prescriptions and high-alert orders. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
— |
| Pharmacist ISCO 2262 ASF proposal |
Checks, dispenses and counts medicines and keeps the records. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Medication Safety & Storage in Guest Facilities (MED-03, Georgian version only) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-SOP-005 PHM-SOP-001 PHA-SOP-002 |
| Nurse ISCO 2221 ASF proposal |
Gives medicines, checks them at the bedside and records each dose. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Medication Safety & Storage in Guest Facilities (MED-03, Georgian version only) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-SOP-005 PHM-SOP-001 PHA-SOP-002 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Medication Safety: Operating SOP-MED-01 End to End (T-08) GMJ Academy: English · Georgian |
Nurses and pharmacists | None |
| Medication Safety & Storage in Guest Facilities (MED-03, Georgian version only) GMJ Academy: Georgian |
Nurses and pharmacists | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HOS-SOP-005 · Medicine storage and temperature control Procedure (SOP) · To keep medicines at the correct temperature, secure and in date. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| PHM-SOP-001 · Medicine storage and temperature monitoring Procedure (SOP) |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| PHA-SOP-002 · Stock management, shortages and expiry Procedure (SOP) · To keep stock available to patients, without shortage or wastage from expiry. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2020). Good storage and distribution practices for medical products (WHO Technical Report Series 1025, Annex 7). Used for: secure storage, temperature control and expiry of medicines (8.4). https://news.gmj.ge/guideline/who-trs-1025-annex-7-good-storage-distribution-practices/
8.5
Controlled Medicines Are Recorded and Counted
Humanitarian settings: MustTransition and fragile: MustStandard: Must
Controlled medicines are recorded in a register, counted at each handover, and signed by two people. Prescribing of opioids is reviewed, and any discrepancy is investigated.
Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. Controlled medicines are high-risk for misuse and diversion. A register and a double count are the simplest way to detect a loss.
Questions the surveyor asks
- Is there a register for all controlled medicines? Every receipt, supply and administration is recorded.
- Is each count double-signed? Two people count, and both sign.
- Are discrepancies investigated? A difference between the register and the stock is an incident, not a note.
How the surveyor verifies this criterion
Sample. The controlled medicines register and count sheets for the last 3 months, and the opioid prescribing reviews.
1. Register is complete
Method. Check the register against the stock and the prescriptions.
Evidence to show. Controlled drugs register (HOS-REG-001).
Pass when. Every entry is complete, and the balance matches the stock.
2. Counts are double-signed
Method. Check the count sheets for two signatures at each handover.
Evidence to show. Controlled medicines register (PHM-FRM-002).
Pass when. Every sampled count is signed by two people.
3. Opioid prescribing is reviewed
Method. Check the review records for sampled opioid prescriptions.
Evidence to show. Opioid prescribing review and diversion monitoring (MNP-SOP-001).
Pass when. Each sampled opioid prescription has a review record.
Immediate fail (any one means the criterion is not met)
- A controlled medicine is missing and not reported.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. A complete register, double-signed counts at each handover, and reviewed opioid prescriptions.
Partial because. The register is kept but not complete, or counts are done by one person.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Prescriber (doctor) ISCO 2212 ASF proposal |
Writes and reviews prescriptions and high-alert orders. | Humanitarian: Essential Transition: Essential Standard: Essential |
Prescribing & Controlled Substance Management (TM-05) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
— |
| Pharmacist ISCO 2262 ASF proposal |
Checks, dispenses and counts medicines and keeps the records. | Humanitarian: Essential Transition: Essential Standard: Essential |
Prescribing & Controlled Substance Management (TM-05) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-REG-001 PHM-FRM-002 MNP-SOP-001 MNP-FRM-001 |
| Nurse ISCO 2221 ASF proposal |
Gives medicines, checks them at the bedside and records each dose. | Humanitarian: Essential Transition: Essential Standard: Essential |
Prescribing & Controlled Substance Management (TM-05) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
PHM-FRM-002 MNP-SOP-001 MNP-FRM-001 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Prescribing & Controlled Substance Management (TM-05) GMJ Academy: English · Georgian |
Nurses and pharmacists | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HOS-REG-001 · Controlled drugs register Register · Records every receipt, supply and administration of a controlled drug, with a count at each shift change. |
Records officer (ISCO 4132) | Chief pharmacist (ISCO 2262) | Records officer (ISCO 4132) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| PHM-FRM-002 · Controlled medicines register Form (record) · Record of every receipt, supply and disposal of controlled medicines. |
Nurse (ISCO 2221) | Clinical pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| MNP-SOP-001 · Opioid prescribing review and diversion monitoring Procedure (SOP) · To keep opioid prescribing under review and to find misuse early. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| MNP-FRM-001 · Opioid prescribing review record Form (record) · Records the reason for an opioid, the alternatives considered, the dose, the review and the stop date. |
Nurse (ISCO 2221) | Clinical pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2025). WHO Guideline on Balanced National Controlled Medicines Policies to Ensure Medical Access and Safety. Used for: safe access to, and control of, controlled medicines (8.5). https://news.gmj.ge/guideline/who-balanced-national-controlled-medicines-policies/
- Centers for Disease Control and Prevention (USA) (2022). Clinical Practice Guideline for Prescribing Opioids for Pain. Used for: review of opioid prescribing (8.5). https://news.gmj.ge/guideline/clinical-practice-guideline-for-prescribing-opioids-for-pain-united-states-2022/
8.6
Medicines Are Reconciled at Admission, Transfer and Discharge
Humanitarian settings: MediumTransition and fragile: MustStandard: Must
The medicines a patient takes are compared at admission, transfer and discharge with the medicines prescribed. Differences are resolved with the prescriber and recorded.
Rating: Medium in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. Medicines are often lost or duplicated at a transition of care. A reconciliation at each point stops errors from being carried into the next setting.
Questions the surveyor asks
- Is a reconciliation done at admission? The home medicines are listed, not assumed.
- Is a reconciliation done at transfer and discharge? Each handover is a risk point.
- Are differences resolved and recorded? A difference left unresolved is an error waiting to happen.
How the surveyor verifies this criterion
Sample. Ten admission, ten transfer and ten discharge records from the last 3 months.
1. Admission reconciliation
Method. Check each admission record for a home medicines list.
Evidence to show. Medicines reconciliation (HOS-SOP-007).
Pass when. A reconciled list is recorded in at least 9 of 10 admissions.
2. Transfer and discharge reconciliation
Method. Check each transfer and discharge record against the prescribed list.
Evidence to show. Medicine reconciliation at admission, transfer and discharge (LTC-SOP-002).
Pass when. A reconciled list is recorded in at least 9 of 10 records for each.
3. Differences resolved
Method. Check each recorded difference for a resolution.
Evidence to show. Medicines management policy (HOS-POL-001).
Pass when. Every difference is resolved and recorded with the prescriber.
Immediate fail (any one means the criterion is not met)
- A discharge is made with no medicines list at all.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Reconciled lists at admission, transfer and discharge, with every difference resolved.
Partial because. Reconciliation is done at admission but not at discharge, or differences are not recorded.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Prescriber (doctor) ISCO 2212 ASF proposal |
Writes and reviews prescriptions and high-alert orders. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-POL-001 |
| Pharmacist ISCO 2262 ASF proposal |
Checks, dispenses and counts medicines and keeps the records. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) The Medication-Use Process (PS-10) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-SOP-007 LTC-SOP-002 HOS-POL-001 |
| Nurse ISCO 2221 ASF proposal |
Gives medicines, checks them at the bedside and records each dose. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) The Medication-Use Process (PS-10) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-SOP-007 LTC-SOP-002 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Medication Safety: Operating SOP-MED-01 End to End (T-08) GMJ Academy: English · Georgian |
Nurses and pharmacists | None |
| The Medication-Use Process (PS-10) GMJ Academy: English · Georgian |
Nurses and pharmacists | Prescribers |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HOS-SOP-007 · Medicines reconciliation Procedure (SOP) · To stop medicines being missed, duplicated or stopped by mistake when a patient moves. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| LTC-SOP-002 · Medicine reconciliation at admission, transfer and discharge Procedure (SOP) · To stop medicines being missed, doubled or stopped by mistake when a resident moves between care settings. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HOS-POL-001 · Medicines management policy Policy · To set one set of rules for medicines in the hospital: storage, controlled drugs, high-alert medicines and reconciliation. Medicine harm is a priority area of the WHO Medication Without Harm challenge. |
Chief pharmacist (ISCO 2262) | Chief executive (ISCO 1120) | Clinical lead (ISCO 1342) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2007). WHO Nine Patient Safety Solutions. Used for: assuring medication accuracy at transitions in care (8.6). https://news.gmj.ge/guideline/who-nine-patient-safety-solutions-2007/
- National Institute for Health and Care Excellence (UK) (2015). Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. Used for: medicines reconciliation (8.6). https://news.gmj.ge/guideline/medicines-optimisation-the-safe-and-effective-use-of-medicines-to-enable-the-best-possible-outcomes/
- World Health Organization (2017). Medication Without Harm: Global Patient Safety Challenge on Medication Safety. Used for: medicines at transitions of care (8.6). https://news.gmj.ge/guideline/medication-without-harm-global-patient-safety-challenge-on-medication-safety/
8.7
Medication Errors Are Reported and Reviewed
Humanitarian settings: MediumTransition and fragile: MustStandard: Must
Every dispensing error, near miss and medication error is reported in a log, reviewed each month, and used to change practice.
Rating: Medium in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. Errors that are not reported cannot be learned from. A simple log and a monthly review turn each near miss into a system fix.
Questions the surveyor asks
- Is there a log of errors and near misses? Near misses count, not only harm.
- Is the log reviewed each month? A log that is never read is not a review.
- Does the review lead to a change? Evidence of a change is the proof of learning.
How the surveyor verifies this criterion
Sample. The error log for the last 6 months and the monthly review minutes.
1. Log is kept
Method. Check the error log for entries over the last 6 months.
Evidence to show. Dispensing error and near-miss log (PHA-REG-002).
Pass when. Entries are recorded with date, medicine and outcome.
2. Review each month
Method. Check the review minutes for the last 6 months.
Evidence to show. Medicines management policy (HOS-POL-001).
Pass when. A review is recorded in at least 5 of the 6 months.
3. Change is made
Method. Check the review minutes for a recorded change to practice.
Evidence to show. Dispensing error and near-miss log (PHA-REG-002).
Pass when. At least one recorded change to practice follows from a review.
Immediate fail (any one means the criterion is not met)
- Errors are not recorded at all.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. A complete log, a monthly review, and a recorded change to practice.
Partial because. The log is kept but not reviewed, or reviews are not followed by change.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Prescriber (doctor) ISCO 2212 ASF proposal |
Writes and reviews prescriptions and high-alert orders. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-POL-001 |
| Pharmacist ISCO 2262 ASF proposal |
Checks, dispenses and counts medicines and keeps the records. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Incident Reporting, Just Culture and Open Disclosure (T-09) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
PHA-REG-002 HOS-POL-001 |
| Nurse ISCO 2221 ASF proposal |
Gives medicines, checks them at the bedside and records each dose. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Safety: Operating SOP-MED-01 End to End (T-08) Incident Reporting, Just Culture and Open Disclosure (T-09) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
— |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Medication Safety: Operating SOP-MED-01 End to End (T-08) GMJ Academy: English · Georgian |
Nurses and pharmacists | None |
| Incident Reporting, Just Culture and Open Disclosure (T-09) GMJ Academy: English · Georgian |
Nurses and pharmacists | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| PHA-REG-002 · Dispensing error and near-miss log Register · Records each dispensing error and near miss, its review and the change made to practice. |
Records officer (ISCO 4132) | Chief pharmacist (ISCO 2262) | Records officer (ISCO 4132) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HOS-POL-001 · Medicines management policy Policy · To set one set of rules for medicines in the hospital: storage, controlled drugs, high-alert medicines and reconciliation. Medicine harm is a priority area of the WHO Medication Without Harm challenge. |
Chief pharmacist (ISCO 2262) | Chief executive (ISCO 1120) | Clinical lead (ISCO 1342) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: reporting and learning from patient safety incidents (8.7). https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
- National Institute for Health and Care Excellence (UK) (2015). Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. Used for: learning from medicines-related patient safety incidents (8.7). https://news.gmj.ge/guideline/medicines-optimisation-the-safe-and-effective-use-of-medicines-to-enable-the-best-possible-outcomes/
Role details: reporting, supervision and training
Each role links to its own terms of reference, which holds the full reporting line, supervision, training and competency record.
Who is responsible for Standard 8
Each criterion below names the positions responsible for it.
| Criterion | Positions responsible or involved | |
|---|---|---|
| 8.1 | Look-Alike, Sound-Alike Medications Are Specifically Managed | Prescriber (doctor) · Pharmacist · Nurse |
| 8.2 | Each Prescription Is Checked Before Dispensing | Prescriber (doctor) · Pharmacist · Nurse |
| 8.3 | High-Alert Medicines Are Double-Checked Before Giving | Prescriber (doctor) · Pharmacist · Nurse |
| 8.4 | Medicines Are Stored Securely and at the Right Temperature | Prescriber (doctor) · Pharmacist · Nurse |
| 8.5 | Controlled Medicines Are Recorded and Counted | Prescriber (doctor) · Pharmacist · Nurse |
| 8.6 | Medicines Are Reconciled at Admission, Transfer and Discharge | Prescriber (doctor) · Pharmacist · Nurse |
| 8.7 | Medication Errors Are Reported and Reviewed | Prescriber (doctor) · Pharmacist · Nurse |
Quality oversight
The quality chain keeps this standard under review, from the governing body down to the teams that run each process.
Related courses in the GMJ Academy
These courses cover the same subjects in more depth or for a specific type of facility. They are optional. They are not required by the criteria.
| Course | Subject |
|---|---|
| High-Alert Medication Safety (PS-03) GMJ Academy: https://academy.gmj.ge/course-search/high-alert-medication-safety-en/ |
High-alert medicines and safe administration |
| Prescribing & Controlled Substance Management (TM-05) GMJ Academy: https://academy.gmj.ge/course-search/asf-tm-05-en/ |
Prescribing and controlled substance management |
| Medication Management & Family Coordination (HC-04) GMJ Academy: https://academy.gmj.ge/course-search/asf-hc-04-en/ |
Medication management and family coordination |
| Medication Safety: Operating SOP-MED-01 End to End (T-08) GMJ Academy: https://academy.gmj.ge/course-search/asf-t-08-en/ |
Medication safety procedure end to end |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 8 apply to?
Every facility that prescribes, dispenses, stores or gives medicines. The table at the top of this page shows each criterion by facility type: all seven criteria apply to eight of the nine facility types and are marked N/A only for fitness and wellness. Each criterion has its own pass rule and its own immediate-fail rule, so each one must be met on its own. Criteria on pain are in Standard 10 (Pain Management).
What is an immediate fail?
An immediate fail is one event or finding that means a criterion is not met, even if everything else in that criterion is in place. For example, if a controlled medicine is missing and has not been reported, criterion 8.5 fails outright, however well the register is kept. Each criterion on this page lists its own immediate fail under “Immediate fail”. Facilities should read these before the survey, because they are the points on which the outcome is decided most quickly.
Which documents do I submit?
The documents are the policies, procedures, forms and registers listed under each criterion in the “Documents: who does each step” table. Records, such as the Dispensing check record (HOS-FRM-009), the Controlled drugs register (HOS-REG-001) or the Dispensing error and near-miss log (PHA-REG-002), are kept as working files. Policies and procedures are signed documents that show the version, date, owner and approver. Have the records ready for the period stated in each criterion, which is the last 3 months for most checks, 30 days for temperature records and 6 months for the error log. You may use your own document if it meets the same check, as long as it is clearly the same record.
Are the ratings the same in every setting?
No. Two criteria are Must in every setting, including humanitarian settings: the pharmacist check of each prescription (8.2) and the recording and counting of controlled medicines (8.5). The other five criteria are Medium in humanitarian settings and Must in transition and fragile and in standard settings.
What must we do about look-alike, sound-alike medicines?
Keep a list for your own stock, not a general awareness of the risk. Every stocked medicine whose name or packaging could be confused with another goes on the list (MNP-REG-001), and the list is reviewed at least once a year. Each listed medicine is stored apart or carries a distinct label, as the policy sets out (MNP-POL-001), and an extra check is recorded when it is dispensed (HOS-FRM-009). The surveyor checks the list against the stock, walks through the storage areas, and reviews the records for 20 dispensed items from the last 3 months. Having no list for your own stock is an immediate fail.
Who must check a prescription before it is dispensed?
A qualified pharmacist, for every prescription. The check covers dose, route, allergies and interactions, and the identity of the patient, and it is recorded on the Dispensing check record (HOS-FRM-009) under the dispensing policy (HOS-POL-002). Counselling given to the patient is recorded too (PHA-FRM-001). The surveyor takes twenty dispensing records from the last 3 months, including at least five supplied out of hours or during system downtime, because that is when checks are most often skipped. Dispensing with no pharmacist check at all is an immediate fail. This criterion is Must in every setting.
Which medicines need a second check before they are given?
High-alert medicines, such as insulin, concentrated potassium, anticoagulants and opioids. The facility keeps its own list (HOS-SOP-006), and each dose is checked by a second qualified person before it is given, with the check recorded on the administration chart. The surveyor reviews twenty administrations from the last 3 months: every medicine given must be on the list, a second person must have checked at least 18 of the 20, and the check must be recorded. Giving high-alert medicines with no second check at all is an immediate fail.
How must medicines be stored?
Locked, with access limited to named staff, and at the temperature the manufacturer specifies. Temperature is recorded every working day, and any reading out of range is acted on. Expired stock is removed from the shelves and recorded as removed. The procedures are HOS-SOP-005 and PHM-SOP-001 for storage and temperature, and PHA-SOP-002 for stock and expiry. The surveyor inspects the storage areas and reviews the temperature records for the last 30 days and the stock and expiry register. Medicines kept unlocked with no temperature records at all are an immediate fail.
How are controlled medicines checked?
Controlled medicines are recorded in a register (HOS-REG-001), counted at each handover, and each count is signed by two people. The balance in the register must match the stock. Opioid prescribing is reviewed, and each review is recorded (MNP-SOP-001, MNP-FRM-001). Any discrepancy is investigated. The surveyor reviews the register and count sheets for the last 3 months and the opioid prescribing reviews. A controlled medicine that is missing and not reported is an immediate fail. This criterion is Must in every setting.
What is medicines reconciliation, and when is it done?
It is the comparison of the medicines a patient actually takes with the medicines prescribed, done at three points: admission, transfer and discharge. Any difference is resolved with the prescriber and recorded. The procedure is HOS-SOP-007. The surveyor reviews ten admission, ten transfer and ten discharge records from the last 3 months and expects a reconciled list in at least 9 of each 10. A discharge with no medicines list at all is an immediate fail.
What must we do with medication errors and near misses?
Report every one in a log (PHA-REG-002), with the date, the medicine and the outcome, review the log every month, and use the review to change practice. The surveyor reads the log for the last 6 months and the review minutes, and expects a review in at least 5 of the 6 months and at least one recorded change to practice that followed from a review. Not recording errors at all is an immediate fail. A log with no entries is not a sign of safety; it usually means errors are not being reported.
What do the colours mean?
Red means Must: the criterion is required in every setting, and criteria that protect life are always red. Yellow means Medium: the criterion is required, but adapted to what a transition setting can realistically do. Green means Minimum: the lowest acceptable level in a humanitarian setting, where resources are very limited. In standard settings every criterion is Must. Each criterion shows its rating for each of the three settings, so a facility can see exactly what applies to it.
Do we have to use your forms and policies?
No. Every policy, procedure, form and course on this page is a reference draft to help you meet the criterion. You can adapt it to your facility, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how. If you use your own document, make sure it covers the same content as the reference and that it is current, signed and dated, so that the assessor can match it to the criterion without difficulty.
What does essential or recommended training mean for my staff?
In the training tables, red means essential: the course is required for that role in that setting. Green means recommended: the course is advised for that role. Yellow means optional. Each course shows its level for humanitarian, transition and fragile, and standard settings, because the requirement can differ between them. Staff evidence is a verified micro-credential in the GMJ Academy micro-credential portfolio, or a training certificate kept in the staff file.
Do we have to use ISCO-08 codes?
The staff tables give each occupation its ISCO-08 code, so that roles can be compared between facilities and countries. You are not required to change your job titles. What matters is that each role named in the standard can be matched to the person who does that job and to the training they have had. If your titles differ, record the match in your staff file so that the assessor can follow it.
Which training do staff need?
The e-learning table under each criterion shows who must take each course and who is recommended. Nurses and pharmacists take Medication Safety: Operating SOP-MED-01 End to End for most criteria, with High-Alert Medication Safety for criterion 8.3, The Medication-Use Process for prescription checks and reconciliation, Prescribing & Controlled Substance Management for criterion 8.5, and Incident Reporting, Just Culture and Open Disclosure for criterion 8.7. Each course name opens the course page in the GMJ Academy. Staff can show evidence through a verified micro-credential in the GMJ Academy micro-credential portfolio, or through a training certificate kept in the staff file.
What will the surveyor see on the day?
The surveyor works through the criteria, following the “Sample” and the checks given for each one. In Standard 8 the surveyor walks through the storage areas to check locks, labels, separation of look-alike medicines, temperature logs and expiry dates. The surveyor then reviews records: dispensing checks, administrations of high-alert medicines, the controlled medicines register and count sheets, reconciliation at admission, transfer and discharge, and the error log with its monthly reviews.
How does the surveyor choose which records to check?
Each criterion states its own sample, such as “Twenty dispensing records from the last 3 months, including at least five out-of-hours or downtime supplies” or “Ten admission, ten transfer and ten discharge records from the last 3 months”. The surveyor uses the sample given on the criterion rather than choosing records to suit the facility. Preparing for the survey means keeping the records for the whole period stated, organised so that any item in the sample can be produced quickly. A facility that cannot produce the sampled records loses the criterion, whatever else it has in place.
What if we do not have the written protocol yet?
A criterion cannot be met on the basis of an unwritten or informal arrangement, because the assessor needs something to check against. If a protocol does not yet exist, write one before the survey, using the reference draft or your own version, and make sure it is signed, dated and in use. Staff must be able to explain it in practice.
Where can I get the full text?
The full text of each criterion, with its rating, why it matters, the assessor checks, the immediate-fail rule and the documents, is on this page. A PDF with the same criteria, for printing and for assessors, can be downloaded from the box at the top of this page. The questions and answers on this page summarise the criteria, and if they ever differ, the criterion text is the authority.
Who can I ask about this standard?
For questions about this standard, contact Accréditation Sans Frontières through the Contact page of this website. Please give the standard number and the criterion (for example 8.3) so that your question can be answered against the right text.
E-learning by standard
These are the GMJ Academy courses named in the criteria of this standard. Each course name opens the course page in the academy. Where a course is published in English and in Georgian, both versions are linked. Evidence of completion is a verified micro-credential in the GMJ Academy micro-credential portfolio, or a training certificate in the staff file.
| E-learning course | Who must take | Who is recommended | Criteria |
|---|---|---|---|
| Medication Safety: Operating SOP-MED-01 End to End (T-08) GMJ Academy: English · Georgian |
Nurses and pharmacists | None | 8.1, 8.2, 8.3, 8.4, 8.6, 8.7 |
| Care & Treatment: Clinical Standards for Accreditation (H-04, Georgian version only) GMJ Academy: Georgian |
Nurses and pharmacists | None | 8.1 |
| The Medication-Use Process (PS-10) GMJ Academy: English · Georgian |
Nurses and pharmacists | Prescribers | 8.1, 8.2, 8.6 |
| High-Alert Medication Safety (PS-03) GMJ Academy: English · Georgian |
Nurses and pharmacists | Prescribers | 8.3 |
| Medication Safety & Storage in Guest Facilities (MED-03, Georgian version only) GMJ Academy: Georgian |
Nurses and pharmacists | None | 8.4 |
| Prescribing & Controlled Substance Management (TM-05) GMJ Academy: English · Georgian |
Nurses and pharmacists | None | 8.5 |
| Incident Reporting, Just Culture and Open Disclosure (T-09) GMJ Academy: English · Georgian |
Nurses and pharmacists | None | 8.7 |
References and guidelines for this standard
The guidelines and references cited in the criteria above are listed here. Each link opens the full text.
- World Health Organization (2007). WHO Nine Patient Safety Solutions. Used for: look-alike, sound-alike medication names (8.1). https://news.gmj.ge/guideline/who-nine-patient-safety-solutions-2007/
- World Health Organization (2017). Medication Without Harm: Global Patient Safety Challenge on Medication Safety. Used for: reducing avoidable harm from medicines (8.1). https://news.gmj.ge/guideline/medication-without-harm-global-patient-safety-challenge-on-medication-safety/
- World Health Organization (2020). Good storage and distribution practices for medical products (WHO Technical Report Series 1025, Annex 7). Used for: secure storage, temperature control and expiry of medicines (8.4). https://news.gmj.ge/guideline/who-trs-1025-annex-7-good-storage-distribution-practices/
- World Health Organization (2025). WHO Guideline on Balanced National Controlled Medicines Policies to Ensure Medical Access and Safety. Used for: safe access to, and control of, controlled medicines (8.5). https://news.gmj.ge/guideline/who-balanced-national-controlled-medicines-policies/
- Centers for Disease Control and Prevention (USA) (2022). Clinical Practice Guideline for Prescribing Opioids for Pain. Used for: review of opioid prescribing (8.5). https://news.gmj.ge/guideline/clinical-practice-guideline-for-prescribing-opioids-for-pain-united-states-2022/
- National Institute for Health and Care Excellence (UK) (2015). Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. Used for: medicines reconciliation (8.6). https://news.gmj.ge/guideline/medicines-optimisation-the-safe-and-effective-use-of-medicines-to-enable-the-best-possible-outcomes/
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: reporting and learning from patient safety incidents (8.7). https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
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