Standards › Standard 47 › Standard operating procedures (SOPs)
SOP · DET-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 47.5
At a glance
- Unexpected deterioration, sepsis and hospital-associated VTE are reviewed at least every quarter.
- Events come from the incident log (NET-REG-001) and the sepsis time register (SEP-REG-001).
- A pattern in the events leads to a written change to practice, with an owner and a date.
- Serious events also go through root cause analysis (INC-SOP-001).
- Stop and get help straight away if: a pattern of events is found and no change to practice is made.
1. Purpose
To find patterns in deterioration, sepsis and VTE events and change practice where a pattern is found (47.5).
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
Unexpected deterioration, sepsis and clots in hospital are events that show where care is failing. Reviewing them regularly is how the hospital learns.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead | Holds the quarterly review and owns the changes | Hospital director |
| Ward manager | Brings the ward’s events to the review | 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. Collect.
- Collect the events of the quarter from the incident log and the sepsis register.
Key point: Collected.
Step 2. Review.
- Review each event and look for a pattern by ward, cause or time of day.
Key point: Reviewed.
Step 3. Change.
- Write each change to practice with an owner and a date.
- Carry out a root cause analysis for any serious event (INC-SOP-001).
Key point: Changed.
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 |
|---|---|---|---|---|
| Quarterly reviews held on schedule | 100% | Quarterly | Clinical lead | Escalate to the hospital director |
| Patterns found with a written change | 100% | Quarterly | Clinical lead | Reopen the review |
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 |
|---|---|---|
| NET-REG-001 | Incident learning log (existing, reused) | Register |
| INC-SOP-001 | Root cause analysis of serious incidents (existing, reused) | SOP |
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)