Standards › Standard 57 › Standard operating procedures (SOPs)
SOP · RTH-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 57.2
At a glance
- Patient identity is verified before every fraction.
- The treatment site and set-up are checked against the plan (RTH-FRM-002).
- If the set-up differs from the plan, treatment is paused for review.
- Stop and get help straight away if: a fraction is given without identity and set-up verification.
1. Purpose
To make sure each fraction is given to the right patient, at the right site, as planned (57.2).
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
To make sure each fraction is given to the right patient, at the right site, as planned (57.2).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Radiographer | Verifies identity and set-up before each fraction | Radiation oncologist |
| Radiation oncologist | Reviews any set-up difference before treatment continues | 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. Identify.
- Verify the patient identity before the fraction.
Key point: Identified.
Step 2. Set up.
- Check the treatment site and set-up against the plan and record it (RTH-FRM-002).
Key point: Set up.
Step 3. Pause.
- If the set-up differs from the plan, pause and review before treatment continues.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Fractions with identity and set-up recorded | 100% | Monthly | Clinical lead | Stop treatment until recorded |
| Set-up differences with a pause and review | 100% | Monthly | Clinical lead | Review the day’s treatments |
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 |
|---|---|---|
| RTH-FRM-002 | Daily treatment verification record | Record |
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
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)