Standard operating procedures

Standard operating procedures

Accountable officers must ensure adequate and up-to-date standard operating procedures (SOPs) are in place within their organisation; these should support strong governance arrangements and must be compliant with the relevant current legal framework.

·      SOPs must cover the following as a minimum:

·      who has access to CDs

·      where and how CDs are stored

·      how CDs are transported within the organisation

·      how CDs are destroyed and disposed of

·      who is alerted if complications or concerns arise or incidents occur

·      what records need to be maintained, including relevant CD register requirements

·      how records of schedule 2 drugs that have been returned by patients are kept and managed

The accountable officer should make sure that additional SOPs are available within the organisation, where required, to ensure all aspects of CD manage-ment and accountability are clearly defined and agreed. Most hospitals will have similar core SOPs but their content and detail may vary, as they should be specifically tailored to the healthcare setting and reflect the roles and responsibilities agreed within the organisation.

Hospital pharmacists are in an ideal position to observe day-to-day prac-tice with CDs in clinical areas and can help to identify when local SOPs may need review or where additional training may be required.