Standards › Standard 33 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · LBT-SOP-007 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 33.11
At a glance
- Each critical value is phoned to a named responsible clinician, not left on a voicemail.
- The recipient reads back the value and confirms receipt.
- Communication happens within the defined time (LBT-REG-007).
- The call and receipt are recorded.
- Stop and get help straight away if: a critical value is left on a voicemail or sent by email and not confirmed.
1. Purpose
To make sure a dangerous result reaches a responsible clinician quickly and is confirmed received (33.11).
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
A critical result, such as a dangerously high potassium, must reach a responsible clinician at once. A result left in a report or on a screen can cost a life.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Senior scientist | Makes the call and records the receipt | Laboratory director |
| Responsible clinician | Confirms the read-back and acts on the value | Medical director |
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. Call.
- Phone the responsible clinician with the patient identifier and the value.
Key point: Called.
Step 2. Read back.
- Ask the recipient to read back the value and confirm receipt.
Key point: Confirmed.
Step 3. Record.
- Record the time, the recipient and the receipt (LBT-REG-007).
Key point: 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 |
|---|---|---|---|---|
| Critical values with receipt confirmed | 100% | Monthly | Senior scientist | Escalate to the laboratory 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 |
|---|---|---|
| LBT-REG-007 | Critical value communication log | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 15189:2022 Medical laboratories: requirements for quality and competence, ISO 9001:2015 for supplier control, and the Global Patient Safety Action Plan 2021–2030 for critical results. |
| 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)