Standards › Standard 11 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PRO-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 11 (Procedure Units), criterion 11.6
At a glance
- Adrenaline and the other emergency drugs are in a known place and ready before any procedure.
- The emergency response is practised, and the team knows its roles.
- Anaphylaxis is treated at once as the protocol sets, and the patient is observed after the event.
- Equipment and drugs are checked on the schedule in HOS-SOP-015.
- Stop and get help straight away if: a procedure starts without adrenaline and resuscitation equipment ready and checked.
1. Purpose
To make sure the unit can treat anaphylaxis and other emergencies in minutes (11.6).
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
Anaphylaxis and other emergencies can happen minutes after an injection. The centre must have the equipment and the training to respond at once.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Medical director | Owns the protocol and the drug list | Clinician |
| Nurse in charge | Checks the kit before each session | Nurse |
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. Check the kit.
- Check adrenaline, airway and resuscitation equipment before each session (HOS-FRM-013).
Key point: Before each session.
Step 2. Treat at once.
- Treat anaphylaxis at once as the protocol sets, and call for help.
Key point: At once.
Step 3. Observe and record.
- Observe the patient after the event and record the response and any transfer.
Key point: Observed and recorded.
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 |
|---|---|---|---|---|
| Sessions with the emergency kit checked before use | 100% | Monthly | Nurse in charge | Escalate to medical director |
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 |
|---|---|---|
| HOS-FRM-013 | Daily resuscitation check record (existing, reused) | Record |
| HOS-SOP-015 | Resuscitation equipment checks (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)