Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-015 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.21
At a glance
- Check the resuscitation trolley or bag at the start of every shift.
- Check every item on the list, including the defibrillator.
- Replace any missing or faulty item at once.
- Check that life support certification is current.
- Stop and get help straight away if: a resuscitation trolley is missing a key item and no replacement is found.
1. Purpose
To make sure resuscitation equipment is ready at every moment (S1.21).
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
When a patient stops breathing, minutes matter. Equipment that is missing or broken, or staff without current life-support training, cost lives.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Nurse in charge | Checks the trolley each shift and signs | Trained |
| Biomedical engineer | Tests the defibrillator and monitors | Biomedical |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Resuscitation trolley checklist | Current | On the trolley |
| Defibrillator with self-test | Working | Checked daily |
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.
- Go through the checklist item by item.
- Check the defibrillator self-test.
Key point: Every item, every shift.
Step 2. Replace.
- Replace any missing or faulty item from the store at once.
Key point: Do not wait for the next delivery.
Step 3. Record.
- Sign the daily record (HOS-FRM-013).
Key point: The signature is the proof.
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 |
|---|---|---|---|---|
| Shifts with recorded check | At least 70% | Monthly | Nurse manager | Escalate to clinical director |
| Staff with current life support certificate | At least 70% | Monthly | 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-FRM-013 | Daily resuscitation check record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Checklist to be set by the resuscitation 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)