PHARMACY AND STORES

ASSOCIATED HOSPITAL

GOVERNMENT MEDICAL COLLEGE KATHUA

SOP FOR PHARMACY AND STORES

Doc. No. 02

GOVT. MEDICAL COLLEGE, Issue Date 22-06-2020

KATHUA
Revision Date 22-12-2020
JAMMU AND KASHMIR
Revision No.

Next Review 22-06-2021

Total Pages 25

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 PHARMACY AND STORES

List of contributors

S.no Name Designation

1 Dr.Yangchen Dolma Assistant Professor

2 Aditya Bhanotra Record Clerk

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 PHARMACY AND STORES

S.No INDEX Page No.

1. About the Department 4

2. Quality Policy 4

3. Quality Objectives 4

4. Indenting of Drugs from District Ware-House 5

5. Local Purchase of Drugs 6

6. Reception of Drugs and Items 7

7. Storage of Drugs 8-10

8. Disposal of Expired Drugs 11

9. Dispensing of Medicines at Pharmacy 12

10. Indenting drugs to patient care area 13

11. Issue of drugs in emergency condition 14

12. Maintaining near- expiry drugs 15

13. Patient education on Drug administration 16

14. Medication Recall 17

15. Prevention of Theft & Pilferage 18

16. Prescription of Narcotic Drugs 19

17. Purchase of External Supplies & Goods 20

18. Purchase of External Supplies & Goods 21

19. Cleaning of Pharmacy 22-24

20. Periodic random checking 25

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 PHARMACY AND STORES

About the Department:

Scope of services - It covers all activities under the purview of medicine, equipment and
goods storage within the hospital.

Timings – Round the clock, 24*7 services.

Quality Policy :

Associated Hospital, GMC kathua is committed to provide service excellence in an equitable

way with best practices in Medicare and maintaining highest standards of quality with
assurance to treat patient with due respect, compassion and dignity in a safe environment.
This would be achieved through:
i. To Place at the core of service Delivery.
ii. To encourage attainment of best practice.
iii. To promote a patient centric service delivery.
iv. To ensure patient, visitors and employees safety.
v. To work towards a continuous improvement of heath indicators.
vi. Universal access to integrated and compressive primary and secondary health
care services
vii. To promote free services to the economically deprived section of society.
Quality Objectives
i. To focus on quality of care of patient.
ii. To improve the performance of all health care professional.
iii. Involvement all employees to participate in Quality improvement.
iv. To monitor, measure and improve performance and to enhance patients
satisfaction (PDCA).
v. To guard, measure and improve patient/employees safety.
vi. To search for patient of Non- Compliance with goals, objectives and standard
though.
 Problem Identification.
 Problem Assessment.
 Finding the Root cause (Root Cause Analysis)
 Solution Generation
 Plan for Solution Implementation
 Implementation of corrective action and monitoring

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Indenting of Drugs from District Ware-House

S No. Activity Responsibility Record

1. Pharmacy-In charge shall maintain an adequate Pharmacy - Indent
stock of at least 1 month Incharge

2. Forecasting of drugs and consumables shall be done Pharmacy - Indent

scientifically based on past month’s consumption Incharge
rate and disease load.
3. Pharmacy in-charge shall prepare list of items and MO Indent
materials to be procured after checking the stock Store/Storekeepe
r
availability. This indent shall be forwarded to
JKMSCL for approval.
4. After approval from concerned official the indent is Pharmacy - Indent
forwarded to Central Medical Store. Incharge

Reference Standard: ME G4.2

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 PHARMACY AND STORES

Local Purchase of Drugs

S No Activity Responsibility Record

1. Local purchase of drugs from a previously approved Pharmacist Stock

register, local
vendor shall be done in case the drug prescribed for the
purchase
patient is out of stock. register
2. In case the patient/patient attendant purchases the drug Pharmacist local
from local market the drug. purchase
register

Reference Standard: ME G4.2

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Reception of Drugs and Items

S No Activity Responsibility Record

1. Drugs shall be received in the hospital from Pharmacy - Challan Sheet
JKMSCL based on the requirement generated and Incharge
sent by the hospital. The drugs are supplied as per
the availability.
2. The drugs received shall be identified and their Pharmacy - Challan sheet, Drug
quantity checked. The drugs received shall be Incharge stock ledger
verified for expiry, brand, quantity and packing
conditions. Pharmacist shall then update the drug
stock ledger.
3. The items and the quantity received shall be Pharmacy - Stock Register
entered in the stock register. Incharge
4. The drugs which are not received shall be noted Pharmacy - Stock Register
and intimated to the MO Store/Storekeeper Incharge
particularly for those required on urgent basis.
5. A list shall be prepared for the drugs received as Pharmacy - List of
damaged or expired (If any). Such drugs shall be Incharge damaged/expired
segregated and a detailed note put up by MO drugs
Store/Storekeeper to JKMSCL for replacement

Reference Standard: ME G4.2

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Storage of Drugs

S No Activity Responsibility Record Keeping

1. The drug stock shall be stored in their respective Pharmacist/Store Nil
places on racks, shelves or in drawers with proper keeper
labelling.
2. Direct storage of cartons on the floor shall be Pharmacist/Store Nil
avoided so as to prevent damage by moisture. keeper

3. Stock shall be arranged neatly in alphabetic order Pharmacist Nil

with the label bearing the name of the product in
front.
4. The Stock with longest shelf life shall be stored Pharmacist Nil
farthest to the back or to the left.
5. Controlled drug substances like narcotics, and Pharmacist Nil
other potent drugs shall be stored in their
designated cupboard/drawer under double lock
system. One key for the same shall be with the
pharmacist and the other with Store-Incharge.
6. High risk Medications like sound alike and look Pharmacist List of High Risk
alike drugs or reagents or chemicals shall be Medications
stored separately and labelled accordingly.
7. A list of commonly used look alike & sound alike Pharmacist List of High Risk
drugs shall be prepared and displayed at the Medications
pharmacy counter. The substances considered in
this list shall be doubly checked to ensure the
name, potency etc.
8. Heavy items shall be stored in lower shelves. Pharmacist Nil
Fragile items shall not be stored at the edges of
the shelves
9. Medications shall be stored at stipulated Pharmacist Nil
temperature areas, protected from excessive light,
dust and humidity. It is essential to follow the
product manufacturers’ storage instructions to the

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extent possible. If not possible, store the products

at most suitable conditions available.
10. Items requiring refrigeration shall be stored Pharmacist Temperature
appropriately. The temperatures should be recording
Register/ Book
checked by designated personnel daily and
recorded in registers. Temperature Monitoring
Book shall be maintained for monitoring of the
temperature of refrigerator
11. Medications that are considered light-sensitive, as Pharmacist Nil
labelled by their respective manufacturers, shall
be stored in closed drawers
12. Unused, Unopened and damaged products shall be Pharmacist Stock Register
stored in a separate area and records maintained
to return the products to the Central Store
13. The storage areas shall always be maintained neat Pharmacist Housekeeping
and tidy at all times. Procedures shall be laid checklist
down for daily & periodic cleaning.
14. Storage areas shall be regularly checked for signs Pharmacist Pest control
of pests, water damage and deterioration due to register
climatic conditions.
15. Stringent storage conditions shall be followed in Pharmacist Nil
case of products like vaccines, kits, sera and other
potent drugs, which require specific storage
conditions to maintain potency.
16. Work instruction for storage of vaccines shall be Pharmacist
displayed at point of use.
17. ILR and deep freezer for vaccine storage should Pharmacist Nil
have functional temperature monitoring devices.
18. Temp. of ILR: Min +2 0 C to 8 0C in case of power Pharmacist Temperature
failure min temp. + 10 0C shall be maintained monitoring
register
19. Temp. of Deep freezer cabinet shall be maintained Pharmacist Temperature
between -15 0 C to -25 0C. monitoring
register
20. Yearly verification of sub stores of the facility shall M.O

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be conducted by the M.O Stores. Stores/Pharmacist

Temperature Control & Monitoring
21. Designated personnel shall be appointed for daily Pharmacist Daily temperature
temperature monitoring. monitoring
checklist
22. The temperature and humidity in the pharmacy Pharmacist Daily temperature
shall be checked daily, using a designated monitoring
thermometer/hygrometer. The temperature shall checklist
be recorded at different times of the day (i.e. in
various shifts).
23. The thermometer should be periodically Pharmacist Equipment
calibrated to ensure correct temperature register
measurement.
24. Periodic service of the air conditioner shall be Pharmacist
done.

Reference Standard: ME G4.2

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Disposal of Expired Drugs

S No Activity Responsibility Record

1. Expired goods shall be stored in separate Pharmacist Expiry Drug
Register
shelf/cupboard marked “EXPIRED GOODS NOT
FOR SALE” to prevent misuse.
2. Due importance shall be given to the expiry date Pharmacist Expiry Drug
Register
of medicines. Periodic checking for expiry date
shall be carried out.
3. Expired drugs shall be segregated and returned to Pharmacist Expiry Drug
Register
Central Medical Store (CMS) and the expiry drug
register shall be updated.
4. A committee formed for the reason shall analyze Expiry Drugs
Committee
the expiry trends.
5. Expired drugs are disposed off in yellow dustbin Pharmacist
and further sent to CBWTF.

Reference Standard: ME G4.2

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Dispensing of Medicines at Pharmacy

S No Activity Responsibility Record

1. No medication shall be dispensed from pharmacy Pharmacist Prescription
without a written prescription.
2. Medication dispensing shall be done with care to Pharmacist Prescription
prevent any medication error. Following shall be
checked before dispensing of medication.
 Medicine prescribed
 Dose of prescribed medicine
 Expiry date of the medicine prescribed
3. On satisfactory checking the pharmacist shall then Pharmacist Drug Dispensing
dispense the drug to the patient (OP) and to Ward register
boy/Aaya in case of Inpatient drug indent
4. While removing medicines, care should be taken Pharmacist Nil
to remove the medication either from the front or
the right hand side of the rack (Goods with later
expiry are placed behind or on the left.)
EEFO: Early expiry first out
FIFO: First in first out.
5. Details of drug dispensed are documented in the Pharmacist Drug Dispensing
drug dispensing register. register

Dispensing High Risk Medications

6. Definition: High-risk medications are drugs that Pharmacist Nil
bear a heightened risk of causing significant
patient harm when they are used in error.
Although mistakes may or may not be more
common with these drugs, the consequences of an
error with these medications are clearly more
devastating to patients.
7. These drugs shall be made available only on Pharmacist Narcotic
provision of written prescription of a qualified prescription
doctor. For Narcotics a separate narcotic
prescription shall be used.
8. The drug, dose, route, time and frequency of Pharmacist Narcotic
administration shall be double checked before prescription

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dispensing of these drugs.

9. Prescriptions that are incomplete, erased or Pharmacist Narcotic
overwritten will be considered as invalid and shall prescription
be rejected for dispensing at pharmacy.
10. For Narcotic prescription the pharmacist shall Pharmacist Narcotic
verbally cross check the prescription with the prescription
treating consultant over phone.
11. After dispensing any narcotic drug the narcotic Pharmacist Narcotic register
register shall be updated by the pharmacist.
12. Points to be noted: Pharmacist Drug dispensing
 Maintain hygiene while dispensing to avoid register
contamination.
 Eye applicaps might need special precaution.

Reference Standard: ME G4.2

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Indenting drugs to patient care area

S No Activity Responsibility Record

1. Dept In-charge shall prepare list of drugs & Ward -Incharge Indent form
consumables in an indent form after checking the
stock availability. This indent shall be forwarded
to Store – Incharge for collecting the stock.
2. The ward boy/aaya shall collect the listed items Ward boy Indent form, Stock
from the store after producing the indent form to register
the Incharge. After providing the listed items the
ward boy/aaya shall then undertake signature of
the store-Incharge in the stock register.

Reference Standard: ME G4.2

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Issue of drugs in emergency condition

S No Activity Responsibility Record

1. Under emergency condition also the same
protocol shall be followed as SOP for “ Dispensing
of medicines at Pharmacy”

Reference Standard: ME G4.2

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Maintaining near- expiry drugs

S No Activity Responsibility Record

1. Pharmacist Stock register
The pharmacy shall always arrange drugs in a
First - In First – Out (FIFO) basis.
2. Near expiry drugs shall always be kept in the front Pharmacist Stock register
row so that the same is dispensed off early before
their expiry date. EEFO basis.
3. Periodic stock check of drugs and consumables Pharmacist Stock register
shall be carried out to ensure that there is no
expiry drugs present in the pharmacy.
4. The expired drugs identified shall be kept Pharmacist Stock register
segregated away from other drugs.
5. Double bin system or double shelf system shall be Pharmacist Stock register
implemented to prevent stock out and to maintain
lead time for next order.
6. Buffer stock of 25% for vaccines/ and 10% for Pharmacist Stock register
syringes shall be kept to prevent stock out

Reference Standard: ME G4.2

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Patient education on Drug administration

S No Activity Responsibility Record

1. After dispensing the medication the Pharmacist Pharmacist Nil
shall educate the patient on the following:.
- Explain the dose, duration of the medication, route
of administration and the instructions as to
missed doses.
- Discuss possible side effects, drug interactions and
strategies to overcome them.

Reference Standard: ME G4.2

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Medication Recall

S No Activity Responsibility Record

1. Medicine shall be recalled to pharmacy or CMS Pharmacist Drug recall
(Central Medical Store) in the following cases. Register
 On intimation from State Drug Authority about
stopping the use of a particular drug.
 On intimation from Central stores about the
inaptness in particular drug supplied.
 In case physical incompatibility is noted or
reported (for e.g. visible contamination in IV
fluid) of particular batch.
2. In case of a drug recall the entire pharmacy stock Pharmacist Drug recall
shall be checked. In case the same reason for Register
recalling is evident in entire stock then the entire
stock shall be removed from pharmacy.
3. The recalled drug stock shall be placed in a Pharmacist Drug recall
designated location away from the dispensing area. Register
4. The drug recall register shall be filled with the name Pharmacist Drug recall
of drug, quantity recalled and reasons for recall. Register

Reference Standard: ME G4.2

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Prevention of Theft & Pilferage

S No Activity Responsibility Record

1. The Pharmacy Incharge shall be Responsible for all Pharmacy- Nil
aspects of the security of drugs & consumables within the Incharge
pharmacy, whereas the store-Incharge shall be
responsible for managing the same in the stores.
2. Access to the Pharmacy & stores shall be restricted to Pharmacy - Signage-
authorized personnel only. Incharge “Admission
with Approval
only”
3. Special consideration shall be given to the storage of Pharmacist Nil
controlled drugs.
4. Stock shall be kept to a level that is appropriate for the Pharmacist Stock Register
demand and replenishment of logistics.
5. The movement of all stock shall be recorded on the Pharmacist Pharmacy
Pharmacy computer system. This will include orders, software
goods received, invoices raised, issues, returns, disposals
and adjustments. Regular reports will be produced.
6. Monthly stock checks & surprise stock checks shall be Pharmacy - Audit reports
undertaken by Chief Pharmacist. Incharge
7. Security cameras can also be installed in the pharmacy & Pharmacy - Nil
store room and near dispensing area for eye watching in Incharge
case of any malpractice.

Reference Standard: ME G4.2

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Prescription of Narcotic Drugs

S No Activity Responsibility Record

1. Narcotic prescription shall be done in narcotic use form Consultant, Narcotic
(prescription) for indoor patient’s .Patient name, age, Pharmacist prescriptio
sex, IP no. shall be present along with the description of n
drug, dose, route, frequency, quantity for 24 hours.
Doctor’s full name, date of prescription and full
signature shall be present in the Narcotic prescription.
2. In case a narcotic is needed for excess quantity more Consultant, Narcotic
than 24 hours, the consultant under which the patient is Pharmacist prescriptio
admitted shall write in the narcotic prescription as n
super prescription for narcotics and shall sign. The
consultant doctor shall mention in the quantity column
for how many days it is needed.
3. The prescribing practitioner shall be responsible for the Consultant, Narcotic
appropriate usage of medications as per the law and Pharmacist prescriptio
regulations (Narcotic Drugs & Psychotropic n
substance Act.

Reference Standard: ME G4.2

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Purchase of External Supplies & Goods

S No Activity Responsibility Record

1. Only in case of stock out and emergency requirement Incharge, Inventory
shall local purchase of drugs & consumables be Store-Incharge, Register
made. RMO,Civil Surgeon
2. Local purchase shall be made only from list of Incharge, List of approved
approved vendors. Store-Incharge, Vendors
RMO,Civil Surgeon
3. An open tender system shall be used for selection of Incharge, EOI
vendors. Store- Incharge
RMO,Civil Surgeon
4. Wherever necessary qualification/ pre Incharge
qualification/ eligibility of the suppliers will be
prepared by the Incharge

Reference Standard: ME G4.2

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Cleaning of Pharmacy

S No Activity Responsibility Record

Cleaning of shelves
1.  Use a clean cloth for cleaning of shelves. Nursing Orderly Housekeeping
 First transfer the contents from the shelves, (e.g. boxes, checklist
strips, bottles etc.) to an empty tray/table if any.
 Wipe the shelf clean with the cloth to remove dust.
 In case of rigid stains/smudges, use water for cleaning.
 After completion, place the medicines appropriately
back onto the shelves.
 Place the cloth in an area allocated for cleaning
materials.
 Repeat the cleaning of shelves after every 2 weeks or
before if required as per location and usage.
 A cleaning register shall be kept to keep records of
cleaning done.
 After cleaning the pharmacist shall check whether all
medications are kept at their labelled locations
Cleaning of Refrigerator
2.  Put off the refrigerator before starting cleaning. Nursing Orderly Housekeeping
 Quickly transfer all the products from the refrigerator checklist
into an empty clean carton (or thermocol box if
available). Take care that no medicines come in direct
contact with the floor. (If an alternate refrigerator is
available in the pharmacy, transfer the medicines to
the second refrigerator, until the cleaning procedure is
completed.)
 After the refrigerator is emptied, clean it from the
inside and outside with a clean wet cloth to remove

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any dirt and stains. Use a mild soap / detergent if

necessary.
 Close the refrigerator door, and switch on the
refrigerator.
 After around half an hour, check that the temperature
is attained in the refrigerator in different zones, using a
thermometer.
 Quickly place back all the products back in the
refrigerator in their specified locations, in a neat
manner.
 Quickly close the door of the refrigerator and fill the
cleaning register and temp log sheet.
 Defrost the refrigerator from time to time (A schedule
shall be fixed for this).
 The refrigerator should be cleaned once in a month
preferably after working hours on a non busy day, or
when customer flow is low.
Cleaning of floor
3.  Clean the floor at the specified/allotted times. Sweeper Housekeeping
 Use a clean mop for cleaning. checklist
 Use a clean bucket, clean water and
disinfectant/phenol.
 Carefully clean all the areas of the floor and corners of
the floor. Rub out any marks/smudges that do not go
easily.
 Refill the bucket with clean water if necessary.
 At the end of cleaning, inspect & ensure that all the
areas of the floor are clean.
 Throw out the dirty water in the sink, clean the mop &
bucket, and keep it back in the allocated place, so that

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it can be found the next time easily.

 Maintain registers to keep records of cleaning done.
 Repeat the cleaning of the floor every day, and when
necessary. Frequency may have to be increased to
twice a day in the rainy season, when the floor gets
mucky more often.
Cleaning of chemical spill
4.  Wear gloves and mask, place tissue paper/sponge on MO
the spill and absorb the spill. Stores/Storekee
 Put the absorbent paper/sponge in a black waste bag per/Pharmacist/
for disposal. Any person
 Pour sodium hypochlorite solution on the spill for 10 handling
minutes and wipe of with wet mop Chemical
 Then wet mop the area with disinfectant & water Reagents
solution

Reference Standard: ME G4.2

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Periodic random checking

S No Activity Responsibility Record

1. Yearly physical verification of inventory shall be done MO, Stores
periodically including surprise visits by the Medical
Officer, Stores.
2. In the physical verification, storage condition of the MO, Stores
drugs, temperature maintenance and stock verification
as per the amount mentioned in the stock register &
analysis of indicators shall be done.
3. The discrepancies observed shall be documented in the MO, Stores
audit report. Corrective action shall be taken on the
discrepancies observed.

Reference Standard: ME G4.2

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