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Module 3C · Medicines and Pain

3 criteria · ASF Health Standards v10 · Draft for review

Each criterion below shows what the surveyor checks, the evidence to show, and what counts as met, partly met or not met.

Colour key: Red = Essential, required in every setting. Green = Recommended. Amber = Standard.

3C.1 Look-Alike, Sound-Alike Medications Are Specifically Managed

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.

Questions the surveyor asks

1. Does a specific, named list of look-alike, sound-alike medications exist for this facility's own formulary? Generic awareness of the concept is not the same as a specific list for what this facility stocks.
2. Are LASA medications stored separately or distinctly labelled to prevent mix-up? Physical or visual separation, not reliance on staff memory alone.
3. Is there a specific check step for LASA medications distinct from general dispensing practice? An additional safeguard specific to this risk, not just standard dispensing care.

Why it 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.

Evidence to show. Look-alike, sound-alike medicines list (current, dated) and a photograph of the storage separation.

Good

• a list of look-alike, sound-alike medicines, with separate storage, labels and a double check at dispensing.

Failure

• two similar-looking vials stored side by side with no warning.

Partly met when

• List not updated: A look-alike list not kept current with stock.
• No separation: Look-alike medicines stored together.

How to implement

• Once: Make the list of look-alike and sound-alike medicines.
• Each new stock: Update the list and the safeguards.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask the pharmacist: which of our medicines look or sound alike, and how are they kept apart?
• What is uploaded: Look-alike, sound-alike medicines list (current, dated) and a photograph of the storage separation.

E-learning. Medication Safety: Operating SOP-MED-01 End to End

3C.2 Opioid Prescribing Is Deliberately Stewarded

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.

Questions the surveyor asks

1. Is there a defined stewardship approach for opioid prescribing, distinct from general high-alert medication management? Specific to opioids — dose, duration, alternatives — not folded generically into broader medication safety.
2. Are non-opioid alternatives considered and documented before opioid prescribing, not just theoretically available? Evidence of actual consideration, not an assumption that alternatives were weighed.
3. Is there monitoring for signs of diversion or misuse, not just appropriate initial prescribing? Stewardship extends beyond the prescribing moment into ongoing awareness.

Why it 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.

Evidence to show. Opioid prescribing guideline (current) and a sample of 10 prescriptions with the review record (anonymised).

Good

• opioid prescribing follows a written approach, with the dose, duration and non-opioid options recorded.

Failure

• a repeat opioid prescription issued with no review.

Partly met when

• Duration not reviewed: Opioid prescribed with no review date.
• Alternatives not considered: No record that non-opioid options were considered.

How to implement

• Each prescription: Record the dose, duration and non-opioid options considered.
• Monthly: Audit the opioid prescriptions.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask the prescriber: for a patient on a long-term opioid, how do you decide the dose, and when do you review it?
• What is uploaded: Opioid prescribing guideline (current) and a sample of 10 prescriptions with the review record (anonymised).

E-learning. Medication Safety: Operating SOP-MED-01 End to End

3C.3 Pain Is Formally Assessed and Reassessed, Not Just Asked About Once

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.

Questions the surveyor asks

1. Is pain assessed using a structured tool on admission, not an informal, unstructured question? A specific, structured scale appropriate to the patient, not a general "how are you feeling" check.
2. Is pain reassessed at defined intervals, particularly after any intervention intended to address it? Reassessment specifically tied to interventions, not just a general periodic check.
3. Are reassessment results used to adjust the care plan, not just recorded and left unactioned? A reassessment that does not influence care provides no benefit over not reassessing at all.

Why it 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.

Evidence to show. Pain assessment tool (current) and a sample of 10 charts showing the scores and reassessments (anonymised).

Good

• structured pain tool used on admission and after each intervention intended to reduce pain, with the scores recorded.

Failure

• a patient in severe pain for a day with no assessment recorded.

Partly met when

• Only on admission: Pain assessed once and not reassessed.
• No score: Pain described in words with no structured score.

How to implement

• On admission: Assess pain with the structured tool.
• After each intervention: Reassess pain and record the score.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask the nurse: how do you assess this patient's pain, and when was it last reassessed after the medicine was given?
• What is uploaded: Pain assessment tool (current) and a sample of 10 charts showing the scores and reassessments (anonymised).

E-learning. Accreditation Training for This Standard