Pharmacy Standard Operating Procedure
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Pharmacy Operations, Dispensing & Medication Management
The Pharmacy Department is responsible for ensuring the safe procurement, storage, dispensing and management of medicines in accordance with applicable laws, Hospital policies and NABH standards. Pharmacy personnel shall ensure that every medicine is dispensed accurately, safely and only against a valid prescription issued by an authorised Registered Medical Practitioner.
"Every medicine dispensed shall be safe, accurate, properly documented and legally authorised."
Applicable Laws & Standards
- Drugs and Cosmetics Act, 1940 and Rules, 1945.
- Pharmacy Act, 1948.
- Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985 (where applicable).
- NABH Medication Management (MOM) Standards.
- NABH Human Resource Management (HRM) Standards.
Core Responsibilities
- Dispense medicines only against a valid prescription issued by an authorised medical practitioner.
- Verify patient details, medicine name, dosage, strength and quantity before dispensing.
- Maintain accurate stock registers and inventory records.
- Monitor expiry dates and remove expired or damaged medicines immediately.
- Store medicines according to manufacturer recommendations and Hospital policy.
- Maintain required storage temperatures for refrigerated medicines.
- Provide medication counselling where appropriate.
- Report adverse drug reactions and medication errors through the prescribed reporting system.
Inventory Management
- Maintain First-Expiry-First-Out (FEFO) inventory practices.
- Conduct periodic stock verification.
- Maintain controlled drug records where applicable.
- Report shortages, damaged stock or discrepancies immediately to the Pharmacy In-charge.
Prescription Verification, Medicine Safety & Professional Responsibilities
"No substitution of any prescribed medicine shall be made without prior approval from the treating doctor."
Prescription Verification
- Verify that every prescription is complete, legible and issued by an authorised Registered Medical Practitioner.
- Clarify doubtful, incomplete or illegible prescriptions with the prescribing doctor before dispensing.
- Dispense only the medicine, strength, dosage form and quantity specified in the prescription.
- No medicine shall be dispensed without a valid prescription where one is legally required.
Medication Safety
- No substitution of prescribed medicines without prior approval from the treating doctor.
- High-alert medicines shall be stored, handled and dispensed according to Hospital policy.
- Controlled drugs shall be maintained with appropriate registers and security measures.
- Refrigerated medicines shall be stored within the prescribed temperature range.
- Expired, damaged or recalled medicines shall not be dispensed under any circumstances.
- Medication errors or near misses shall be reported immediately to the Pharmacy In-charge and documented according to Hospital policy.
Professional Conduct
- Maintain confidentiality of patient and prescription information.
- Provide medicines courteously and professionally.
- Educate patients on dosage, storage and precautions whenever appropriate.
- Maintain a clean, organised and secure pharmacy environment.
- Comply with Hospital SOPs, statutory requirements and NABH standards.
Serious Violations
- Dispensing medicines without a valid prescription.
- Substituting prescribed medicines without the treating doctor's approval.
- Dispensing expired, damaged or recalled medicines.
- Failure to maintain stock or controlled drug records.
- Improper storage of medicines resulting in loss of quality or safety.
- Falsification of pharmacy records or inventory documents.
- Disclosure of confidential patient or prescription information.
Non-Compliance
Failure to comply with this SOP, applicable pharmaceutical laws, Hospital policies or NABH standards may result in counselling, retraining, competency reassessment, suspension of pharmacy duties or disciplinary action, depending on the seriousness of the violation. Patient safety and medication accuracy shall always be the highest priority.