Standards › Standard 4 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · ACS-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
At a glance
- Beds are set to the low position when the patient is in them, with brakes locked.
- The call system and personal items are within reach.
- Mobility equipment is available in the sizes needed and is in working order.
- Each item is checked on the schedule, and faulty items are taken out of use.
- Stop and get help straight away if: a patient is left in a high bed with brakes off, or a faulty mobility aid is in use.
1. Purpose
To keep beds and mobility equipment safe for each patient to use (4.6, 4.7).
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 patient who needs a walking frame or a wheelchair but finds none, or finds one that is broken, is put at risk. Having the right aids, in the right sizes, and checking them on a schedule keeps them ready.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Ward nurse | Sets the bed and checks the call system | Nurse |
| Equipment lead | Checks and tags mobility equipment | Technician |
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. Bed.
- Set the bed low, lock the brakes and check the call system is in reach (ACS-FRM-003).
Key point: Low, locked, in reach.
Step 2. Mobility equipment.
- Check each walking aid and wheelchair on the schedule.
- Tag and remove any item that is faulty (EQP-FRM-001).
Key point: Faulty means out of use.
Step 3. Size.
- Check that the sizes in stock meet the needs of the patients on the ward.
Key point: The right size is available.
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 |
|---|---|---|---|---|
| Beds checked each shift | At least 90% | Monthly | Ward manager | Escalate to clinical director |
| Mobility equipment checked on schedule | 100% | Monthly | Equipment 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 |
|---|---|---|
| ACS-FRM-003 | Bed, mobility equipment and call system check | Check |
| ACS-REG-001 | Mobility equipment 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 |
E-learning for this document
- Slip, Trip & Fall Prevention (FALL-01)
- Safety & Emergency Preparedness (H-05)
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)