Standards › Standard 31 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DEN-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 31.13
At a glance
- Each clinical staff member is trained in dental medical emergencies and has a recorded role.
- Emergency drills are rehearsed at the set interval (DEN-REG-004).
- The emergency equipment is used as trained (HOS-FRM-013 for the resuscitation record).
- Every emergency is recorded and reviewed.
- Stop and get help straight away if: a clinical staff member on duty has not been trained in medical emergencies.
1. Purpose
To make sure the team responds to a medical emergency in the chair quickly and in the right order (31.13).
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
A dental emergency happens quickly, and the first minutes decide the outcome. Every clinical staff member, not only the dentist, must be trained to respond.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead | Leads the response and assigns roles | Clinical director |
| Each team member | Carries out the assigned role | Clinical lead |
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. Recognise and call.
- Stop treatment, call for help and call the emergency number in the clinic.
Key point: Called.
Step 2. Assign roles.
- The clinical lead assigns the airway, breathing, circulation and equipment roles.
Key point: Assigned.
Step 3. Treat and record.
- Treat by the trained sequence and record the emergency and its outcome (HOS-FRM-013).
Key point: Recorded.
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 |
|---|---|---|---|---|
| Clinical staff trained in the emergency sequence | 100% | Annual | 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-REG-004 | Dental emergency equipment and drug check register | Register |
| HOS-FRM-013 | Resuscitation record (existing, reused) | 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)