Standards › Standard 54 › Policies
Policy · DRM-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 54.3
At a glance
- Laser and light devices are used only by staff trained and signed off for each device.
- Before each treatment the skin type, the device settings and the contraindications are checked and recorded.
- Eye protection is worn by the patient and everyone in the room during treatment.
- Each use is recorded in the device log (DRM-REG-002).
- Stop and get help straight away if: a laser or light device is used by a person not signed off for it, or without eye protection.
1. Purpose
To make sure laser and light devices are used safely, by trained staff, with checks and eye protection (54.3).
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
To make sure laser and light devices are used safely, by trained staff, with checks and eye protection (54.3).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead | Signs off operators and owns the device safety programme | Hospital director |
| Operator | Checks the patient, sets the device and records the use | 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. Check.
- Check the skin type, contraindications and device settings before each treatment.
Key point: Checked.
Step 2. Protect.
- Give eye protection to the patient and everyone in the room.
Key point: Protected.
Step 3. Record.
- Record each use in the device log (DRM-REG-002).
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 |
|---|---|---|---|---|
| Uses by a signed-off operator | 100% | Monthly | Clinical lead | Stop the device for that operator |
| Uses with eye protection and checks recorded | 100% | Monthly | Clinical lead | Retrain and re-audit |
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 |
|---|---|---|
| DRM-REG-002 | Laser and light device use log | Register |
| AES-FRM-001 | Aesthetic procedure consent and reconsideration record (existing, reused) | Record |
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)