Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-012 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.14
At a glance
- Use only the hospital code list for internal emergency alerts.
- Every staff member knows what each code means.
- Call the code by the code name, never by a plain-language call.
- Drill every code at least once a year.
- Stop and get help straight away if: two different code systems are in use for the same alert.
1. Purpose
To make sure one set of alert codes is used, understood and drilled, so that the right team responds at once (S1.14).
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 an emergency, staff must understand an alert at once. One code system, known to everyone, and drilled, makes that possible.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical governance lead | Owns the code list and the training | Governance |
| Duty manager | Calls and stands down codes | Senior manager |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Hospital code list (one list) | Current | On the wall of each area and on the staff badge card |
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. Call the code.
- Call the code name and the location on the hospital system.
Key point: Use the code, not a description.
Step 2. Respond.
- The named team responds as shown on the code list.
Key point: Each team knows its role.
Step 3. Stand down and record.
- The duty manager stands down the code and records the time.
Key point: The record is the drill result.
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 |
|---|---|---|---|---|
| Staff trained on codes | At least 70% | Yearly | Clinical governance lead | Escalate to chief executive |
| Each code drilled in the last 12 months | 100% | Yearly | Clinical governance lead | Escalate to chief executive |
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 |
|---|---|---|
| HOS-REG-004 | Rehearsal and drill record | Records each drill |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Code list to be set by the hospital and confirmed by the Committee. |
| 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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