HOS-PLN-001: Mass-casualty and utility failure plan

Standards › Standard S1 › Plans and templates

Plan / template · HOS-PLN-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: System S1 (Hospital), criterion S1.12

At a glance

Follow this plan when there are mass casualties, or when power, water or oxygen fails.
The duty manager declares the incident and calls the response team.
Each person knows their role on the card in their area.
Rehearse the plan at least once a year.
Stop and get help straight away if: oxygen or power fails and no one has been told what to do.

1. Purpose

To keep patients safe and care going when many patients arrive at once, or when a key utility fails (S1.12).

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 hospital that loses power, water or oxygen, or receives a mass casualty, needs a plan that people have practised. A plan on the shelf does not work under pressure.

5. Responsibilities

Role	Responsibility	Competence
Duty manager	Declares the incident; leads the response	Senior manager
Clinical lead	Sets clinical priorities	Senior clinician
Estates lead	Restores power, water and oxygen supply	Estates

6. Materials and equipment

Item	Requirement	Condition
Role cards for each area	Current	Displayed in each area
Back-up power and oxygen supply	Tested monthly	Estates log

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. Declare.

The duty manager declares the level of incident.
Call the response team.

Key point: Declare early.

Step 2. Prioritise.

Use the triage tool to sort patients.
Use the role card.

Key point: Care follows the triage, not the arrival.

Step 3. Keep utilities running.

Switch to back-up.
Check oxygen levels every hour and move patients to working supply.

Key point: Oxygen is the priority.

Step 4. Stand down and review.

Stand down when the risk ends.
Hold a debrief within 72 hours and record the actions.

Key point: The debrief is where the plan improves.

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
Rehearsal done in the last 12 months	100%	Yearly	Duty manager	Escalate to chief executive
Back-up power and oxygen tested	100%	Monthly	Estates lead	Escalate to chief executive

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-004	Rehearsal and drill record	Records each drill
EMG-SOP-001	Fire safety and evacuation	Evacuation in an utility failure

17. Evidence

Reference	Note
E-009	Plan content to be checked against the WHO Hospital Safety Index (2017).
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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