Standards › Standard 54 › Standard operating procedures (SOPs)
SOP · DRM-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 54.2
At a glance
- Biopsies, excisions and other minor skin procedures use sterile technique (PRO-SOP-005).
- Hand hygiene is done before each procedure (HH-SOP-001).
- Instruments are single-use or sterilised to the standard, and sharps are disposed of at once.
- Each procedure is audited for technique (PRO-FRM-005).
- Stop and get help straight away if: a skin procedure is started without sterile technique, or reusable instruments are used without sterilisation.
1. Purpose
To make sure minor skin procedures are done with sterile technique, to prevent infection (54.2).
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 minor skin procedures are done with sterile technique, to prevent infection (54.2).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dermatologist | Carries out procedures under the technique and audits them | Clinical lead |
| Nurse | Sets up the sterile field and checks the instruments | Dermatologist |
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.
- Do hand hygiene and set up the sterile field.
- Check that instruments are single-use or sterilised.
Key point: Prepared.
Step 2. Procedure.
- Carry out the procedure with sterile technique and dispose of sharps at once.
Key point: Done.
Step 3. Audit.
- Audit a sample of procedures each month (PRO-FRM-005).
Key point: Audited.
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 | 100% | Monthly | Clinical lead | Retrain and re-audit |
| Instruments sterilised or single-use | 100% | Each procedure | Nurse | Stop the procedure |
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-SOP-005 | Sterile technique and infection control in procedures (existing, reused) | SOP |
| PRO-FRM-005 | Sterile technique audit record (existing, reused) | Record |
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)