Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-009 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.9
At a glance
- Keep the critical value list current and approved.
- The laboratory calls each critical result to the responsible clinician within the set time.
- The clinician acts and records the action and the time.
- Log every critical result on HOS-REG-002.
- Stop and get help straight away if: a critical result is reported with no clinician action recorded.
1. Purpose
To make sure a dangerous result reaches the clinician quickly and is acted on, with a record (S1.9).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A critical laboratory result that is reported late, or not acted on, can cost a life. Each one needs a named action and a time limit.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Laboratory lead | Maintains the critical list and makes the calls | Laboratory |
| Responsible clinician | Receives, acts and records | Doctor or nurse in charge |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Critical values list | Approved, reviewed yearly | Checked each year |
| Critical result log (HOS-REG-002) | Current | Used for every call |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Identify.
- Check each result against the critical list.
Key point: The list is short and clear.
Step 2. Call.
- Call the responsible clinician within the set time.
- Read back the result and the patient identity.
Key point: Read back, every time.
Step 3. Act and record.
- The clinician acts and writes the action and the time on the log.
Key point: An action recorded is the closure.
Step 4. Escalate if not reached.
- If the clinician is not reached in the set time, call the duty clinical lead.
Key point: Never leave a critical result unreported.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Critical results reported within the set time | At least 70% | Monthly | Laboratory lead | Escalate to clinical director |
| Critical results with action recorded | 100% | Monthly | Laboratory lead | Escalate to clinical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HOS-REG-002 | Critical result log | Log used in every step |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Time limits to be set by the laboratory and confirmed by the Committee; |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
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