Medical Incident Report Template
A free medical incident report template for healthcare teams. Document patient safety incidents and near misses. No signup required.
What is a medication administration SOP?
A medication administration SOP is a step-by-step procedure that tells clinical staff how to safely give medications to patients. It covers who is authorised, what checks to complete, how to document, and what to do when something goes wrong.
The template
Medication Administration SOP Template
MEDICATION ADMINISTRATION SOP
Organisation name:
[Your organisation]
SOP reference:
[SOP-MED-XXX]
Version:
[1.0]
Status:
[Draft / Active]
Effective date:
[Date]
Review date:
[Date]
Prepared by:
[Name and role]
Approved by:
[Name and role]
Department:
[Department name]
SECTION 1 - PURPOSE
What is this SOP for?
[Describe the purpose in one or two sentences]
SECTION 2 - SCOPE
Who does this SOP apply to?
[List all roles covered]
Who is NOT covered?
[List exclusions]
What is NOT covered here?
[List procedures handled by a separate SOP]
SECTION 3 - LEGAL FRAMEWORK
This SOP must be read alongside:
[List relevant policies and regulations]
Medications are administered under:
[Prescription / PGD / protocol - state which]
SECTION 4 - AUTHORISED ROLES
Authorised to administer:
[List authorised roles]
NOT authorised:
[List excluded roles]
SECTION 5 - PROCEDURE
5.1 BEFORE ADMINISTRATION
Step 1 - Training and competency
[What training must be completed first]
Step 2 - Patient consent
[How consent is obtained]
Step 3 - Patient identity check
[Two identifiers used at your organisation]
Step 4 - Allergy check
[How allergy status is confirmed]
Step 5 - Medication chart check
[How staff verify name, dose, route, time]
Step 6 - Expiry and batch check
[How expiry date and batch number are checked]
Step 7 - High-alert medication double check
[Which medications require a double check and how]
5.2 DURING ADMINISTRATION
Step 8 - Hand hygiene
[Hand hygiene requirement - reference Hand Hygiene SOP]
Step 9 - Medication preparation
[When and how medication is prepared]
Step 10 - Administration
[Route confirmation and patient observation during]
5.3 AFTER ADMINISTRATION
Step 11 - Documentation
[When and where to record - see Section 6]
Step 12 - Patient observation
[Observation period and what to monitor]
Step 13 - Adverse reactions
[Who to notify and where to report]
Step 14 - If medication not administered
[What to document and who to notify]
SECTION 6 - DOCUMENTATION REQUIREMENTS
Record immediately after administration - not before.
Required fields for every administration:
[List all required fields]
Required fields if medication withheld or refused:
[List required fields]
SECTION 7 - HIGH-ALERT MEDICATIONS
Medications requiring independent double check:
[List your organisation's high-alert medications]
Double-check process:
[Who checks, when, and how it is documented]
SECTION 8 - CONTROLLED DRUGS
Not covered here. Refer to:
[Reference to your controlled drug SOP]
SECTION 9 - RESPONSIBILITIES
Organisation level:
[Role responsible for governance]
Department level:
[Role responsible locally]
Individual staff:
[Staff responsibility]
SECTION 10 - TRAINING
Required training:
[List mandatory modules]
Competency:
[How and when assessed]
SECTION 11 - MEDICATION ERRORS
Step 1:
[Immediate patient safety action]
Step 2:
[Who to notify first]
Step 3:
[Who to notify next]
Step 4:
[Reporting system and timeframe]
Step 5:
[Documentation requirements]
Step 6:
[Do not alter existing documentation]
SECTION 12 - AUDIT AND REVIEW
Review frequency:
[How often]
Reviewed by:
[Role or committee]
Audit process:
[How compliance is audited]
Non-compliance:
[Escalation process]
SECTION 13 - REFERENCES
[List legislation, standards, and policies]
SECTION 14 - DEFINITIONS
Administration:
[Define]
High-alert medication:
[Define]
Double check:
[Define]
Controlled drug:
[Define]
PGD:
[Define]
PSD:
[Define]
Adverse drug reaction:
[Define]
SECTION 15 - SIGN-OFF
Prepared by:
Name:Role:Date:
Reviewed by:
Name:Role:Date:
Approved by:
Name:Role:Date:
Next review:
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What this template covers
Purpose
what the SOP aims to achieve
Scope
which roles are covered and which are not
Legal framework
policies and regulations this SOP sits under
Authorised roles
who can and cannot administer medications
Full procedure
14 steps across before, during, and after
Documentation
what to record after every administration
High-alert medications
which require a double check and how
Controlled drugs
reference to your separate SOP
Responsibilities
organisation, department, and individual level
Training
required modules and competency assessment
Medication errors
six-step process
Audit and review
how compliance is monitored
References
legislation and standards
Definitions
key terms
Sign-off
prepared, reviewed, approved, next review date
How to use this template
Copy the template
Copy from this page and paste into Word, Google Docs, or Notion.
Fill in the header
Complete the SOP reference, version, dates, and names before anything else.
Complete Sections 1 to 4 with your pharmacy lead
Scope, legal framework, and authorised roles need pharmacy input.
Complete Section 5 based on your local policy
Fill in each step placeholder based on how your organisation works.
Complete Sections 6 and 7 carefully
Documentation and high-alert medications vary - check your existing policy first.
Get sign-off in Section 15
An SOP is a governance document and must be approved by an authorised person.
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