Standards › Standard 4 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · ACS-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
At a glance
- Walk each patient route, corridor, stair, ramp and toilet each quarter.
- Check the handrails, the lighting and the floor.
- Remove any trip hazard at once; mark it if it cannot be removed.
- Record each hazard and the date it is closed.
- Stop and get help straight away if: a trip hazard is found on a patient route and left with no mark and no action.
1. Purpose
To find and fix the environment hazards that cause falls (4.1, 4.5, 4.8).
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 cable, a box or a mat on the floor is among the commonest causes of falls in a ward. Clear routes, with any hazard that cannot be removed marked, keep patients moving safely.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Estates and facilities manager | Leads the survey and the fixes | Management |
| Ward staff | Report hazards the same shift | Trained staff |
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. Walk the route.
- Walk the route with the survey form (ACS-FRM-001) and check handrails, lighting, floors and clutter.
Key point: Walk it as a patient would.
Step 2. Fix.
- Remove the hazard at once, or mark it and put a plan in place to fix it.
Key point: Remove first.
Step 3. Close.
- Record the close date and check it on the next survey.
Key point: Closed and checked.
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 |
|---|---|---|---|---|
| Survey findings closed within the set time | At least 90% | Quarterly | Estates and facilities manager | 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 |
|---|---|---|
| ACS-FRM-001 | Environmental falls-risk survey record | Survey |
| PSF-GDL-001 | Falls prevention in hospital patients | Guideline |
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 |
E-learning for this document
- Slip, Trip & Fall Prevention (FALL-01)
- Safety & Emergency Preparedness (H-05)
- Emergency Preparedness and Fire Safety (T-10)
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)