Standards › Standard 31 › Policies
Policy · DEN-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 31.15
At a glance
- Sedation is given only by a clinician competent in the technique (STF-FRM-001).
- Monitoring is continuous from start to discharge and recorded (DEN-FRM-005).
- The emergency equipment for sedation is checked before each case (DEN-REG-004).
- A patient is not sedated without an assessment and consent.
- Stop and get help straight away if: a patient is sedated with no competent clinician, no monitoring or no emergency equipment.
1. Purpose
To make sure sedation is given safely, only by competent clinicians, and monitored from start to discharge (31.15).
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
Sedation and general anaesthesia in a dental clinic carry the same risks as in hospital. They must be given only by staff with the competence to manage them, with continuous monitoring.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Approves who may sedate and the technique | Medical director |
| Sedating clinician | Assesses, sedates and monitors the patient | Clinical director |
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. Assess.
- Assess the patient and record the fitness for sedation.
Key point: Assessed.
Step 2. Sedate and monitor.
- Sedate under the approved technique and monitor continuously (DEN-FRM-005).
Key point: Monitored.
Step 3. Recover.
- Keep the patient monitored through recovery until discharge criteria are met.
Key point: Discharged.
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 |
|---|---|---|---|---|
| Sedations with a continuous monitoring record | 100% | Monthly | Clinical director | Escalate to the medical 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 |
|---|---|---|
| DEN-FRM-005 | Sedation monitoring record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the CDC guidelines for infection control in dental health-care settings (Kohn et al., 2003), ISO 17665 for moist-heat sterilisation, the Minamata Convention on Mercury (2013), IAEA Specific Safety Guide SSG-46 (2018), Council Directive 2013/59/Euratom, and the ADA guidelines on sedation (2016). |
| 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)