Standard 3 · applies to facilities that prescribe or give medicines
Medicines and Pain
Three criteria for medicines and pain: look-alike and sound-alike medicines, opioid stewardship, and structured pain assessment and reassessment. Most documents are new (MNP-); the medicines policy, high-alert medicines procedure, second-check record and controlled drugs register are existing documents, reused where the process is the same.
Two kinds of document
Means of verification. The policies, registers, forms and plans the surveyor checks. The organisation submits them.
Recommended. SOPs and guidelines that support good practice. They are held on site but are not verified.
How a surveyor reads each criterion
Why it matters→
Sample→
Method and evidence→
Pass ruleor
Immediate fail
How strict is Standard 3, by setting
Each row adds up to the total number of criteria on this page.
Standard
Medications with names or packaging that could be confused with another are identified on a specific list and managed with distinct safeguards — separated storage, distinct labelling, or an independent check — not treated the same as any other medication.
Why this criterion matters. Two drugs that look or sound alike are a common cause of serious dispensing errors. Naming them on a list and giving them distinct safeguards stops a mix-up before it reaches the patient.
Sample. Take the look-alike and sound-alike list, and check 10 ward and pharmacy medicine stores and 10 dispensing records from the last month for listed medicines.
How the surveyor verifies this
1. A current list of look-alike and sound-alike medicines exists.
Method. Read the list and check its review date.
Evidence to show. Look-alike and sound-alike medicines list (MNP-REG-001).
Pass when. The list is reviewed within the last 3 months.
2. Each listed medicine has a safeguard in place.
Method. Check the storage and labelling of each listed medicine in the 10 stores.
Evidence to show. Store check record.
Pass when. Every listed medicine has a safeguard in place.
3. Dispensing of listed medicines includes the independent check.
Method. Check the dispensing record for each listed medicine in the sample.
Evidence to show. Dispensing check record (HOS-FRM-009).
Pass when. At least 90% of listed-medicine dispensing has the independent check recorded.
Immediate fail (any one means the criterion is not met)
- A listed look-alike or sound-alike medicine is stored or labelled like any other medicine.
Documents
Means of verification. The surveyor checks these. Submit them.
- MNP-POL-001 · Look-alike and sound-alike medicines
Why it is here. The look-alike and sound-alike safeguards and near-miss reporting.
Submit the approved policy with version and date, and evidence it is in use. - MNP-REG-001 · Look-alike and sound-alike medicines list
Why it is here. The list of medicines with their safeguards.
Submit the register extract for the sample period. - HOS-FRM-005 · High-alert second-check record
Why it is here. The second-check record (existing, reused).
Submit the completed form for the sample period.
Recommended. Good practice, held on site. Not verified by the surveyor.
- HOS-SOP-006 · High-alert medicines
Why it is here. High-alert medicines procedure (existing, reused).
E-learning
- Medication Safety: Operating SOP-MED-01 End to End (T-08)
- Care & Treatment: Clinical Standards for Accreditation (H-04)
References
- Institute for Safe Medication Practices (ISMP). List of Confused Drug Names. Horsham, PA: ISMP.
Standard
Opioid prescribing follows a defined stewardship approach — appropriate dose and duration, consideration of non-opioid alternatives, and monitoring for signs of diversion or misuse — led by a trained, designated person or a physician champion where no dedicated pharmacy function exists. Opioids are managed as a distinct risk, not simply as one more high-alert medication.
Why this criterion matters. Opioids can relieve pain but they also cause harm when they are over-prescribed, given for too long, or not monitored. A stewardship approach keeps the dose and duration to what the patient needs.
Sample. Review the opioid prescriptions for the last 3 months: 10 prescriptions, the designated steward's review record, and the controlled drug register for the same period.
How the surveyor verifies this
1. Opioids are prescribed with a stewardship review and a stop or review date.
Method. Check each of the 10 prescriptions for the review and the date.
Evidence to show. Opioid prescribing review record (MNP-FRM-001).
Pass when. Every sampled opioid has a review and a stop or review date.
2. A designated steward or physician champion leads the process.
Method. Check the appointment record for the steward or champion.
Evidence to show. Appointment record.
Pass when. A named steward or champion is in post.
3. The controlled drug register is checked for misuse and diversion.
Method. Check the monthly register review for the period.
Evidence to show. Controlled drugs register (HOS-REG-001) and review record.
Pass when. The monthly review is recorded for each month, with any concern reported.
Immediate fail (any one means the criterion is not met)
- An opioid continues with no review, or signs of misuse are seen and not reported.
Documents
Means of verification. The surveyor checks these. Submit them.
- MNP-POL-002 · Opioid stewardship
Why it is here. Opioid stewardship, from the first prescription to the stop date.
Submit the approved policy with version and date, and evidence it is in use. - MNP-FRM-001 · Opioid prescribing review record
Why it is here. The prescribing review record.
Submit the completed form for the sample period. - HOS-REG-001 · Controlled drugs register
Why it is here. The controlled drugs register (existing, reused).
Submit the register extract for the sample period.
Recommended. Good practice, held on site. Not verified by the surveyor.
- MNP-SOP-001 · Opioid prescribing review and diversion monitoring
Why it is here. The monthly review and the diversion checks.
E-learning
- Prescribing & Controlled Substance Management (TM-05)
- Medication Safety: Operating SOP-MED-01 End to End (T-08)
References
- Dowell, D., Ragan, K.R., Jones, C.M., Baldwin, G.T., Chou, R. (2022). CDC Clinical Practice Guideline for Prescribing Opioids for Pain, United States, 2022. MMWR Recommendations and Reports, 71(No. RR-3), 1–95. Open source
Standard
Every patient's pain is assessed using a structured tool on admission and reassessed at defined intervals, particularly after any intervention intended to address it — not asked about once informally and left unrevisited.
Why this criterion matters. Pain asked about once on admission is quickly forgotten. Assessing it with a structured tool, and again after treatments, shows whether the treatment is working and when it must change.
Sample. Take 20 inpatients from the last month. Check the admission pain score and the score after each recorded intervention for each patient.
How the surveyor verifies this
1. Each patient has a structured pain assessment on admission.
Method. Check the pain chart for a score on admission for each of the 20 patients.
Evidence to show. Pain assessment chart (MNP-FRM-002).
Pass when. At least 90% of patients have a structured score on admission.
2. Pain is reassessed at the set interval and after each intervention.
Method. Check the chart for reassessment after each intervention in the sample.
Evidence to show. Pain assessment chart.
Pass when. At least 90% of interventions have a reassessment recorded.
3. Scores that do not fall are reported to the clinician.
Method. Check each score that did not fall for a clinician report.
Evidence to show. Pain assessment chart.
Pass when. Every score that did not fall was reported.
Immediate fail (any one means the criterion is not met)
- A patient in pain has no structured assessment on admission, or uncontrolled pain is not escalated.
Documents
Means of verification. The surveyor checks these. Submit them.
- MNP-POL-003 · Pain assessment and management
Why it is here. Pain assessment and management rule.
Submit the approved policy with version and date, and evidence it is in use. - MNP-FRM-002 · Pain assessment chart
Why it is here. The pain score chart.
Submit the completed form for the sample period. - HOS-POL-001 · Medicines management policy
Why it is here. Medicines management policy for pain medicines (existing, reused).
Submit the approved policy with version and date, and evidence it is in use.
Recommended. Good practice, held on site. Not verified by the surveyor.
- MNP-SOP-002 · Structured pain assessment and reassessment
Why it is here. How pain is scored and reassessed.
E-learning
- Care & Treatment: Clinical Standards for Accreditation (H-04)
- Clinical & Medical Care in Long-Term Care (LTC-04)
- Planned course: Pain assessment and reassessment for inpatient teams. New course planned.
References
- Ferreira-Valente, M.A., Pais-Ribeiro, J.L., Jensen, M.P. (2011). Validity of four pain intensity rating scales. Pain, 152(10), 2399–2404. Open source