Standards › Standard BASIS › Standard operating procedures (SOPs)
SOP · SIR-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: B2.6
At a glance
- Every serious incident is reported to the clinical director the same day, and the patient is kept safe and supported.
- A named investigator is appointed within 5 working days, and the investigation follows a recognised root cause analysis method.
- The investigation findings and an action plan with owners and dates are approved by the governing body.
- The patient and family are told the outcome, through the disclosure process (CAN-POL-001).
- Stop and get help straight away if: a serious incident is not reported the same day, or no investigation is started.
1. Purpose
To make sure every serious incident is reported, investigated thoroughly, and turned into action that prevents it happening again (B2.6).
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 |
|---|---|
| Serious incident | An unexpected event that causes, or could cause, death, serious injury or serious harm to a patient, a member of staff or a visitor, or a major loss of service. |
| Root cause analysis | A structured method that looks at the system factors behind an event, rather than blaming an individual. |
| Action plan | The list of changes agreed from the investigation, each with an owner, a due date and a way of checking it has worked. |
4. Background
To make sure every serious incident is reported, investigated thoroughly, and turned into action that prevents it happening again (B2.6).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Receives every serious incident the same day, appoints the investigator, and reports to the governing body | Governing body |
| Investigator | Leads the investigation, interviews those involved, and writes the report with the action plan | Clinical director |
| Governing body | Approves the report and action plan, and checks progress each quarter | Owner or board |
| All staff | Report any serious incident the same day and keep evidence safe | Ward or department 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. Report.
- Report the incident to the clinical director the same day, using the incident form.
- Keep the patient safe and supported, and preserve the records and equipment involved.
Key point: Incident reported the same day.
Step 2. Appoint.
- The clinical director appoints an investigator with no direct involvement in the event, within 5 working days.
Key point: Investigator appointed.
Step 3. Investigate.
- Collect the records, interview those involved, and map the events and system factors using a recognised root cause analysis method.
- Complete the report within the timescale set by the governing body (a draft of 45 working days is suggested).
Key point: Report completed.
Step 4. Act and close.
- Agree an action plan with an owner and due date for each action, and check each action when it is due.
- Tell the patient and family the outcome through the disclosure process (CAN-POL-001), and record it in the register (SIR-REG-001).
Key point: Actions agreed and outcome shared.
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 |
|---|---|---|---|---|
| Serious incidents reported the same day | 100% | Quarterly | Clinical director | Escalate to the governing body |
| Investigations completed within the set timescale | 90% or more | Quarterly | Clinical director | Review the investigator workload and timescales |
| Action plans with owner and due date | 100% | Quarterly | Clinical director | Escalate to the governing body |
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
- Investigators complete root cause analysis training before their first investigation, and refresh it every three years.
- All staff are told how to report a serious incident at induction.
16. Related documents
| ID | Title | Use |
|---|---|---|
| SIR-REG-001 | Serious incident register (existing) | Register |
| CAN-POL-001 | Duty of candour and disclosure policy (existing) | Policy |
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 |
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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)