Standards › Standard 6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DAY-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 6.2
At a glance
- Sedation and anaesthesia are given only by staff trained and credentialed for the level given.
- Monitoring matches the level.
- A written response to each complication is in place and practised.
- Each credential is checked before the staff member gives sedation.
- Stop and get help straight away if: sedation or anaesthesia is given by a staff member without the credential for that level.
1. Purpose
To match the level of sedation to the staff, the monitoring and the response available (6.2).
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
Anaesthesia and sedation carry serious risk, and the level of care depends on who gives them. Each staff member must be trained and credentialed for the level they give, and each patient must be monitored throughout.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead anaesthetist | Sets the levels and the response | Anaesthetist |
| Credentialing lead | Checks each credential (DAY-REG-001) | Management |
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. Match.
- Check the staff member’s credential is for the level of sedation planned.
Key point: Credential matches level.
Step 2. Monitor.
- Monitor at the level set for the sedation (SRG-POL-002).
Key point: Monitoring matches level.
Step 3. Respond.
- If a complication occurs, follow the written response and call for help as the plan sets.
Key point: The response is written.
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 |
|---|---|---|---|---|
| Sedation given by credentialed staff | 100% | Monthly | Lead anaesthetist | Escalate to chief executive |
| Complications with written response followed | 100% | Monthly | Lead anaesthetist | Escalate to clinical 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 |
|---|---|---|
| DAY-REG-001 | Sedation credential register | Register |
| SRG-POL-002 | Anaesthesia safety and monitoring | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the ASA Standards for Basic Anesthetic Monitoring (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
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)