SRG-POL-002: Anaesthesia safety and monitoring

Policy · SRG-POL-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 2.2

At a glance

Anaesthesia follows a written protocol for each type and level.
The patient is monitored continuously from induction to recovery.
Monitoring is matched to the patient’s risk and the level of anaesthesia.
Anaesthetic equipment is checked before each list.
Stop and get help straight away if: a patient is anaesthetised with no monitoring, or on equipment that has not been checked.

1. Purpose

To keep the patient safe throughout anaesthesia, with monitoring matched to their risk (2.2).

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

Anaesthesia is the highest-risk part of the day for many patients. Continuous monitoring through the whole procedure, matched to the level of anaesthesia, is the standard that finds the problem early.

5. Responsibilities

Role	Responsibility	Competence
Lead anaesthetist	Owns the protocol and reviews incidents	Anaesthetist
Anaesthetist	Monitors and records throughout	Anaesthetist

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. Check before.

Check the anaesthetic machine and equipment before the first case (SRG-FRM-003).
Assess the patient’s risk and choose the monitoring level.

Key point: Equipment and risk checked first.

Step 2. Monitor.

Record vital signs, oxygenation, ventilation and temperature at the set interval, from induction to recovery (SRG-FRM-002).

Key point: Continuous, not occasional.

Step 3. Recover.

Hand over to recovery with the monitoring record, and monitor until the patient is safe to leave.

Key point: Monitoring continues after surgery.

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
Cases with monitoring record complete	100%	Monthly	Lead anaesthetist	Escalate to chief executive
Machines checked before first case	100%	Daily	Theatre manager	Escalate to chief executive

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
SRG-FRM-002	Anaesthesia record and monitoring chart	Record
SRG-FRM-003	Anaesthesia machine and equipment check	Check
HOS-POL-001	Medicines management policy	Medicines

17. Evidence

Reference	Note
E-009	Monitoring standard based on the ASA Standards for Basic Anesthetic Monitoring (2020).
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)

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