Standards › Standard 16 › Standard operating procedures (SOPs)
Procedure · PED-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
At a glance
- Measure the child’s weight, or confirm it on the day, before any weight-based dose is calculated.
- A weight carried from an earlier visit is checked against the child before it is used.
- Calculate the dose on the weight, and have a second person check the calculation.
- Record the weight and dose on PED-FRM-006.
- Stop and get help straight away if: a dose is calculated from a weight that has not been measured or confirmed.
1. Purpose
To make sure each weight-based dose is calculated on a measured or confirmed weight and checked by a second person (16.1, 16.11).
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 child’s dose is calculated from their weight. If the weight is not measured or is guessed, every calculation after it is wrong, and the error is often not noticed.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Nurse or doctor preparing the dose | Measures or confirms the weight and calculates the dose | Clinician |
| Second person | Checks the calculation before the dose is given | Clinician |
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. Measure the weight.
- Measure or confirm the weight on the day, and record it with its date.
Key point: Measured today.
Step 2. Calculate.
- Calculate the dose on the weight, and note the medicine and unit.
Key point: Calculated.
Step 3. Check.
- A second person checks the calculation and signs PED-FRM-006 before the dose is given.
Key point: Checked by two.
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 |
|---|---|---|---|---|
| Weight recorded before each weight-based dose | 100% | Monthly | Clinical lead for paediatrics | 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 |
|---|---|---|
| PED-FRM-006 | Weight and dose record | Record |
| PED-POL-001 | Paediatric care: age, size and weight | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Pocket book of hospital care for children (2013) and the UN Convention on the Rights of the Child (1989). |
| 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)