Standards › Standard 11 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PRO-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 11 (Procedure Units), criterion 11.5
At a glance
- Each procedure has a written complications pathway, with a named contact reachable at the time of the procedure.
- Serious reactions have a route to hospital, agreed in advance (AMC-SOP-001).
- Each complication is recorded (PRO-FRM-004) with its outcome.
- Each complication is reviewed within the set time.
- Stop and get help straight away if: a serious complication has no named contact or route to hospital.
1. Purpose
To manage complications through a defined pathway, with a route to hospital (11.5).
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
Complications happen even in a safe centre. A defined pathway, with a named contact available at the time, means the patient is treated quickly and the team learns from it.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Medical director | Owns the pathway and the hospital route | Clinician |
| Named contact | Available at the time of each procedure | 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. Name the contact.
- Name the on-call contact for each day of procedures and give the number to the team.
Key point: Named and reachable.
Step 2. Follow the pathway.
- Treat the complication as the pathway sets, and transfer to hospital for a serious reaction.
Key point: Pathway, then hospital.
Step 3. Record and review.
- Record each complication on PRO-FRM-004 and review it within the set time.
Key point: Recorded and reviewed.
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 |
|---|---|---|---|---|
| Complications with a recorded outcome | 100% | Monthly | Medical director | 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 |
|---|---|---|
| PRO-FRM-004 | Complication record | Record |
| AMC-SOP-001 | Clinic emergency response and transfer to hospital (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the ASF Expert Committee consensus and the WHO Guidelines for Safe Surgical Care and Safe Procedures (2009). |
| 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)