Standards › Standard 2 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · SRG-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2.3
At a glance
- Give antibiotic prophylaxis within the set window before incision.
- Prepare the skin with the approved agent, and let it dry.
- Use sterile technique and change gloves if they are breached.
- Dress the wound and record the closure.
- Stop and get help straight away if: an antibiotic is given outside the set window, or skin preparation is skipped.
1. Purpose
To apply the bundle the same way for every procedure (2.3).
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
Infections after surgery are preventable with a set of checkable practices. A bundle, followed for every procedure and measured, is what makes prevention real.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Anaesthetist | Gives antibiotic prophylaxis in the window | Anaesthetist |
| Scrub nurse | Prepares the field and records sterile technique | Theatre nurse |
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. Antibiotic.
- Give the prophylactic antibiotic within the set window before incision.
- Record the time on the record.
Key point: Time is part of the dose.
Step 2. Skin preparation.
- Prepare the skin with the approved agent, and let it dry before incision.
- Remove hair only if it obstructs the site, with clippers.
Key point: Dry before incision.
Step 3. Sterile technique.
- Keep sterile field. Change gloves if breached. Record any break.
Key point: Break recorded, not hidden.
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 |
|---|---|---|---|---|
| Antibiotic given within the window | At least 90% | Monthly | Infection prevention lead | Escalate to clinical 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 |
|---|---|---|
| SRG-FRM-004 | Surgical site infection bundle compliance record | Record |
| HOS-SOP-014 | Healthcare-associated infection surveillance and response | Surveillance |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global Guidelines for the Prevention of Surgical Site Infection (2018). |
| 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)