Medicines Management Protocol (Standard Operating Procedure)

1. Purpose

To ensure the safe, effective, and legal management of medicines, minimising risk to patients, staff, and the organisation.

2. Scope

This SOP applies to all staff involved in prescribing, ordering, receiving, storing, administering, monitoring, and disposing of medicines.

3. Responsibilities

• Clinical Lead / Prescriber: Prescribing medicines appropriately and reviewing treatment.

• Medicines Manager / Practice Manager: Oversight of medicines management, audits, and compliance.

• Clinical Staff: Safe administration, documentation, and patient monitoring.

• All Staff: Reporting errors, near misses, or concerns.

4. Prescribing

• Medicines must be prescribed only by authorised, competent practitioners.

• Prescribing must follow current clinical guidelines and local formularies.

• Patient allergies, contraindications, and interactions must be checked.

• Clear documentation of medicine name, dose, route, frequency, and duration is required.

5. Ordering and Receipt of Medicines

• Medicines must be ordered from approved suppliers only.

• Deliveries must be checked against the order for accuracy, damage, and expiry dates.

• Controlled drugs (if applicable) must be checked and signed for by two authorised staff members.

6. Storage

• Medicines must be stored according to manufacturer instructions.

• Refrigerated medicines must be kept between 2–8°C, with temperatures recorded daily.

• Controlled drugs must be stored in a locked cabinet compliant with legal requirements.

• Access to medicines must be restricted to authorised staff only.

7. Administration

• The 5 Rights must always be followed: right patient, right medicine, right dose, right route, right time.

• Patient identity must be confirmed prior to administration.

• Medicines must be administered in accordance with the prescription and SOP.

• Any refusal, omission, or error must be documented and escalated.

8. Documentation

• All medicines administered must be recorded accurately and contemporaneously.

• Records must include date, time, dose, batch number (where required), and staff signature.

• Errors and adverse events must be reported using the incident reporting system.

9. Monitoring and Review

• Patients must be monitored for effectiveness, side effects, and adherence.

• Medicines should be reviewed regularly and discontinued when no longer required.

• High‑risk medicines require enhanced monitoring.

10. Controlled Drugs (if applicable)

• Managed in line with national legislation and regulations.

• Accurate registers must be maintained and reconciled regularly.

• Any discrepancies must be reported immediately.

11. Disposal of Medicines

• Expired or unused medicines must be disposed of safely via approved routes.

• Controlled drugs require witnessed disposal and documentation.

• Medicines must never be disposed of in general waste or wastewater systems.

12. Training and Competency

• Staff must receive appropriate training before handling medicines.

• Competency must be assessed and refreshed regularly.

• Training records must be maintained.

13. Audit and Review

• Regular audits of medicines management must be undertaken.

• This SOP must be reviewed at least annually or following significant change or incident.

14. Incident Management

• All medication errors and near misses must be reported.

• Incidents will be investigated, and learning shared to prevent recurrence.

15. References

• National medicines legislation and professional guidance

• Local clinical governance policies

Approved by: Caroline Balazs 
Date: 01/01/2026
Review Date: 01/01/2027