Standards › Standard 11 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PRO-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 11 (Procedure Units), criterion 11.7
At a glance
- Each injection and procedure uses sterile technique: hand hygiene, sterile field, single-use needles and gloves (HH-SOP-001).
- Single-use items are never reused.
- Sterile technique is audited each month (PRO-FRM-005).
- Infection is recorded in the surveillance register (HOS-REG-005).
- Stop and get help straight away if: an injection or procedure is given without sterile technique, or a single-use item is reused.
1. Purpose
To stop infection passing through the skin barrier at every injection and procedure (11.7).
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
Every injection breaks the skin, which is the body’s main barrier to infection. Sterile technique for each one is the simplest way to prevent infection from the procedure itself.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Infection control lead | Audits and trains the team | Nurse |
| Practitioner | Uses sterile technique for every 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. Prepare.
- Hand hygiene, sterile field and single-use items before each procedure (HH-SOP-001).
Key point: Every procedure.
Step 2. Do not reuse.
- Use single-use items once and dispose of them at the point of use.
Key point: Single use.
Step 3. Audit.
- Audit each practitioner each month on PRO-FRM-005.
Key point: Audited monthly.
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 |
|---|---|---|---|---|
| Procedures with sterile technique observed | 95% | Monthly | Infection control lead | 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 |
|---|---|---|
| PRO-FRM-005 | Sterile technique audit record | Record |
| HH-FRM-001 | Hand hygiene observation audit tool (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Guidelines on Hand Hygiene in Health Care (2009) and the WHO Guidelines for Safe Surgical Care (2016). |
| 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)