Standards › Standard 6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DAY-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 6.5
At a glance
- Every procedure has the pre-procedure checks recorded before the patient goes to theatre.
- The checks cover identity, consent, fasting, allergies, medicines, imaging and results.
- The surgical safety check (SRG-FRM-001) is completed with them.
- A check not done stops the procedure until it is done.
- Stop and get help straight away if: a patient goes to theatre with a pre-procedure check not done or not recorded.
1. Purpose
To catch the errors that the pre-procedure checks find before the patient is anaesthetised (6.5).
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
The pre-procedure checks, including the surgical safety check, catch wrong-site, wrong-patient and missing-equipment errors. Each check done and recorded is the proof that it was done.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Pre-admission nurse | Carries out and records the checks | Nurse |
| Surgeon | Confirms the consent and the site | Surgeon |
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. Check.
- Check identity, consent, fasting, allergies, medicines, imaging and results (DAY-FRM-004).
Key point: Every item, every patient.
Step 2. Stop.
- If any check is not done, the patient does not go to theatre until it is.
Key point: A gap stops the list.
Step 3. Safety check.
- Complete the surgical safety check with the team in theatre (SRG-FRM-001).
Key point: Then the team pause.
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 pre-procedure checks recorded | 100% | Monthly | Lead nurse | 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-FRM-004 | Pre-procedure check record | Record |
| SRG-FRM-001 | Surgical safety checklist record | Safety check |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Surgical Safety Checklist (2009). |
| 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
- Ophthalmology & Day Surgery Safety (AMB-15)
- Patient Identification, Informed Consent and Patient Rights (T-07)
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)