Standards › Standard 48 › Standard operating procedures (SOPs)
SOP · HOV-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 48.5
At a glance
- Falls, pressure injuries and handover-related incidents are reviewed together every quarter.
- Events come from the falls log (PSF-FRM-001), the pressure injury register (PRS-REG-001) and the incident log (NET-REG-001).
- A pattern in the events leads to a written change, with an owner and a date.
- Serious events also go through root cause analysis (INC-SOP-001).
- Stop and get help straight away if: a pattern across events is found and no change is made.
1. Purpose
To find patterns across falls, pressure injuries and handover incidents, and change practice where a pattern is found (48.5).
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
Falls, pressure injuries and handover failures often share causes. Reviewing them together shows the patterns that a single review would miss.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead | Holds the quarterly review and owns the changes | Hospital director |
| Ward manager | Brings the ward’s events to the review | 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. Collect.
- Collect the quarter’s falls, pressure injuries and handover incidents from the logs.
Key point: Collected.
Step 2. Review.
- Review the events together and look for a pattern by ward, shift or cause.
Key point: Reviewed.
Step 3. Change.
- Write each change with an owner and a date.
- Carry out a root cause analysis for any serious event (INC-SOP-001).
Key point: Changed.
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 |
|---|---|---|---|---|
| Quarterly reviews held on schedule | 100% | Quarterly | Clinical lead | Escalate to the hospital director |
| Patterns found with a written change | 100% | Quarterly | Clinical lead | Reopen the review |
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 |
|---|---|---|
| PSF-FRM-001 | Falls log (existing, reused) | Log |
| NET-REG-001 | Incident learning log (existing, reused) | Register |
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
- Slip, Trip & Fall Prevention (FALL-01)
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)