Standards › Standard 29 › Standard operating procedures (SOPs)
Procedure · HC-SOP-011 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 29.35
At a glance
- A problem found after a visit, such as a fall discovered later, is reported on discovery, with the time it happened recorded (INC-POL-001).
- Reporting is not judged on whether the caregiver could have known at once.
- Delayed discovery is reviewed as a pattern.
- The review uses the incident process (INC-SOP-001).
- Stop and get help straight away if: a fall found the next morning is recorded as the caregiver’s fault for not reporting at once.
1. Purpose
To make sure incidents discovered late in an unsupervised home are reported and learned from (29.35).
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
In a home where no one else is present, a problem can go unnoticed for days. Incident reporting must allow for that delay, and not assume a problem was reported at once.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Home care service lead | Owns the reporting process | Clinician or manager |
| Caregiver or family member who finds a problem | Reports on discovery | Staff |
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. Report on discovery.
- Report the incident on discovery, and record the estimated time it happened.
Key point: Reported.
Step 2. Review without blame.
- Review the delay under the incident process, without treating it as personal fault by default.
Key point: Reviewed.
Step 3. Look for patterns.
- Review delayed-discovery incidents as a group each quarter.
Key point: Patterns reviewed.
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 |
|---|---|---|---|---|
| Delayed-discovery incidents reported and reviewed | 100% | Quarterly | Home care service lead | Escalate to 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 |
|---|---|---|
| INC-SOP-001 | Root cause analysis of serious incidents (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global strategy and action plan on ageing and health 2016-2030, WHO Integrated care for older people (ICOPE) guidelines (2017), and WHO guidance on migrant health. |
| 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)