Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-009 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.40
At a glance
- A crew member exposed to blood, a needle injury or infection follows the set response at once.
- Wash or flush the site and report to the crew lead the same hour.
- Arrange a clinical review and any post-exposure treatment within the set time.
- Record the exposure.
- Stop and get help straight away if: an exposed crew member has no review and no record of the exposure.
1. Purpose
To protect the crew after an exposure, and to record it so that follow-up is not lost (S6.40).
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 crew member exposed to blood, a needle injury or a patient’s infection needs immediate care and a record. Without a set response, the exposure is missed and the crew member is not protected.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Crew lead | Starts the response and reports the exposure | Trained crew |
| Occupational health lead | Arranges review and follow-up | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
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. First aid.
- Wash the skin or flush the eye at once.
- Do not squeeze the wound.
Key point: Immediate care first.
Step 2. Report.
- Tell the crew lead the same hour.
- Complete the exposure record.
Key point: Same hour.
Step 3. Review.
- Arrange clinical review and any post-exposure treatment within the time set in the protocol.
Key point: Time matters.
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 |
|---|---|---|---|---|
| Exposures reported the same hour | 100% | Quarterly | Crew lead | Escalate to chief executive |
| Exposures with clinical review in time | 100% | Quarterly | Occupational health 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 |
|---|---|---|
| T-09 | Incident reporting (course) | Learning |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. |
| 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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