Standards › Standard 63 › Standard operating procedures (SOPs)
SOP · SHO-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 63.1
At a glance
- Every handover between clinicians uses a structured method (SBAR or I-PASS) at each shift change, team change and ward move (HND-FRM-001).
- Each handover covers identity, diagnosis, medicines, allergies, risks, set results and due actions, and the receiver reads back the key actions.
- A deteriorating or high-risk patient is handed over at the bedside, with the latest early warning score and the named senior clinician.
- A patient moved between wards or facilities travels with a written handover.
- Stop and get help straight away if: a clinician leaves a shift, or a patient is moved, with no handover given and received.
1. Purpose
To make sure care passes between clinicians and teams safely, with no key information lost (63.1 to 63.4).
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
Communication failures during handover are a recognised cause of patient harm. The WHO Patient Safety Curriculum Guide (2007) describes structured handover as a way of reducing omitted information and errors. A standard method means that every clinician knows what to expect, and what to ask.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Ward lead | Makes sure the handover method is used at each change | Clinical lead |
| Clinician giving handover | Gives the structured handover and asks for read-back | Ward lead |
| Clinician receiving handover | Repeats back the key actions and signs the record | Clinician giving handover |
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.
- Check the observations, the early warning score, the medicines and the set results before the handover.
Key point: Prepared.
Step 2. Hand over.
- Give the structured handover face to face or by call, using the checklist (HND-FRM-001).
Key point: Handed over.
Step 3. Confirm.
- The receiver reads back the key actions, and both clinicians sign the record (HOS-FRM-004).
Key point: Confirmed.
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 |
|---|---|---|---|---|
| Handovers using the structured method | 100% | Monthly | Ward lead | Retrain and observe the clinician |
| Handovers with read-back and signatures | 100% | Monthly | Ward lead | Review the handover with the team |
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 |
|---|---|---|
| HND-FRM-001 | Structured handover checklist (existing, reused) | Form |
| HOS-FRM-004 | Handover record (existing, reused) | Form |
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)