AES-SOP-003: Sedation and anaesthesia safety

Standards › Standard 32 › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · AES-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 32.4

At a glance

Sedation and anaesthesia are given only by a competent clinician (AES-POL-001).
Monitoring is continuous from start to discharge and recorded (AES-FRM-003).
Emergency equipment and drugs are checked before each case (HOS-FRM-013).
A patient is not discharged until the discharge criteria are met.
Stop and get help straight away if: a patient is sedated or anaesthetised with no competent clinician, no monitoring or no emergency equipment.

1. Purpose

To keep patients safe during sedation and anaesthesia in an aesthetic setting (32.4).

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

Sedation and anaesthesia in an aesthetic clinic can cause serious harm if the person giving it is not trained, or if the patient is not monitored. Credentialed staff and monitoring keep it safe.

5. Responsibilities

Role	Responsibility	Competence
Clinical director	Approves the sedation and anaesthesia list and the setting	Medical director
Sedating clinician	Assesses, sedates, monitors and discharges	Clinical director

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. Assess and check.

Assess fitness, check the equipment and confirm the clinician’s competence.

Key point: Checked.

Step 2. Sedate and monitor.

Monitor continuously and record each entry (AES-FRM-003).

Key point: Monitored.

Step 3. Recover.

Keep the patient monitored until the discharge criteria are met.

Key point: Discharged.

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
Cases with continuous monitoring recorded	100%	Monthly	Clinical director	Escalate to the 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
AES-FRM-003	Sedation and anaesthesia monitoring record	Record

17. Evidence

Reference	Note
E-009	Based on the WHO guidance on patient rights and informed consent, the WHO Global Patient Safety Action Plan 2021–2030, the American Dental Association guidelines on sedation and general anaesthesia (2016) for the sedation principles adapted to aesthetic practice, and the American Heart Association guidelines for cardiopulmonary resuscitation (2020).
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

Aesthetic & Injectable Medicine Accreditation (AMB-09)

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)

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