Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-011 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.16, S6.17
At a glance
- Drivers are trained for moving patients safely before they drive a patient vehicle.
- Long journeys have planned breaks.
- Drivers and crew report fatigue before the shift.
- Records of training and rest are kept.
- Stop and get help straight away if: a driver without patient-transport training drives a patient, or a long journey runs without a planned break.
1. Purpose
To keep patients and crew safe on the road (S6.16, S6.17).
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 tired driver or crew member makes mistakes that are hard to predict. Long journeys need planned breaks and a rule for when to stop, not a decision made when the driver is already exhausted.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dispatch lead | Plans breaks and rosters | Trained dispatcher |
| Driver | Reports fatigue and takes planned breaks | Trained driver |
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. Train.
- Train each driver in patient moving, safe loading and the vehicle’s features before first patient transfer.
Key point: Trained before patients.
Step 2. Plan rest.
- Plan breaks on every long journey, set by the distance and time.
Key point: Breaks are planned.
Step 3. Report fatigue.
- A driver who is tired reports it before the journey and is replaced if needed.
Key point: Fatigue is reported, not hidden.
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 |
|---|---|---|---|---|
| Drivers trained before first patient transfer | 100% | Quarterly | Dispatch lead | Escalate to chief executive |
| Long journeys with planned break | 100% | Monthly | Dispatch lead | Escalate to clinical lead |
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 |
|---|---|---|
| PTR-REG-001 | Escort and crew credential and pre-shift register | Register |
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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