Standards › Standard 53 › Standard operating procedures (SOPs)
SOP · ALR-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 53.2
At a glance
- Anaphylaxis is recognised from its early signs and treated as an emergency at once (PRO-SOP-004).
- Adrenaline is given at the dose and route in the written protocol, and the time is recorded.
- Adrenaline and the emergency kit are stocked, checked and in date (ALR-REG-001).
- Each episode is recorded and reviewed (PRO-FRM-006).
- Stop and get help straight away if: anaphylaxis is suspected and adrenaline is not given without delay, or the adrenaline in the clinic is out of date.
1. Purpose
To make sure anaphylaxis is recognised and treated immediately, with the emergency kit ready (53.2).
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
To make sure anaphylaxis is recognised and treated immediately, with the emergency kit ready (53.2).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Treating clinician | Recognises and leads the response | Clinical lead |
| Nurse | Gives adrenaline and keeps the kit ready | Treating 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. Recognise.
- Recognise the early signs of anaphylaxis (airway, breathing, circulation, skin).
Key point: Recognised.
Step 2. Treat.
- Give adrenaline at the protocol dose and route, and call for help.
- Record the time of each dose.
Key point: Treated.
Step 3. Check and review.
- Check the kit each day (ALR-REG-001). Review each episode (PRO-FRM-006).
Key point: Checked.
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 |
|---|---|---|---|---|
| Episodes with adrenaline given at once | 100% | Each episode | Clinical lead | Review the episode |
| Daily kit checks completed and in date | 100% | Daily | Nurse | Restock at once |
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 |
|---|---|---|
| ALR-REG-001 | Anaphylaxis episode and adrenaline check register | Register |
| PRO-SOP-004 | Anaphylaxis and emergency response in procedure units (existing, reused) | SOP |
17. Evidence
| Reference | Note |
|---|---|
| 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
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)