FLD-POL-002: Standards adapted under constraint: what may change and what may not

Policy · FLD-POL-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 9.3, 9.4

At a glance

Some steps change under constraint, such as equipment and supplies. Safety steps do not change.
The surgical checks, sterilisation, anaesthesia monitoring and identity checks always apply.
Each shortage has a written, approved alternative, approved before use by the field unit lead.
Any alternative is recorded at the time it is used.
Stop and get help straight away if: a safety step (checklist, sterilisation, monitoring, identity check) is skipped, or a shortage is handled with no written alternative.

1. Purpose

To make clear which safety steps are never relaxed, and which alternatives are allowed (9.3, 9.4).

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 clear which safety steps are never relaxed, and which alternatives are allowed (9.3, 9.4).

5. Responsibilities

Role	Responsibility	Competence
Field unit lead	Approves each alternative	Clinician
Pharmacist or supply lead	Records shortages and alternatives	Pharmacist

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. Hold the non-negotiables.

Keep the surgical checklist, sterilisation, anaesthesia monitoring and two-person identity checks at every site.

Key point: These never change.

Step 2. Use approved alternatives.

Where blood or a medicine is short, use only an alternative the field unit lead has written down and approved before use, and record the use.

Key point: Only listed alternatives.

Step 3. Record the use.

Record each alternative used, the reason and the approving clinician.

Key point: Every use is 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
Alternatives used that were approved in writing before use	100%	Monthly	Field unit lead	Escalate to the coordinating authority

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
SRG-POL-001	Surgical safety checklist and team pause (existing, reused)	Policy
BLD-SOP-006	Emergency release of blood (existing, reused)	Procedure

17. Evidence

Reference	Note
E-009	Based on the Sphere Handbook, Humanitarian Charter and Minimum Standards in Humanitarian Response (2018).
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

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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)

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