Standards › Standard 43 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · TXP-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 43.4
At a glance
- Each recipient is evaluated against the documented clinical eligibility criteria (TXP-FRM-002).
- Consent covers realistic outcomes, risks and alternatives.
- The recipient is given time to consider before signing.
- The evaluation and consent are reviewed by a second clinician.
- Stop and get help straight away if: a recipient is listed for transplant with no documented evaluation or consent.
1. Purpose
To make sure recipients are selected on clinical grounds and choose transplant with full information (43.4).
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 transplant recipient must be fit for the procedure and understand its risks. A documented evaluation and informed consent make sure the decision is sound.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Transplant clinician | Evaluates the recipient and leads the consent discussion | Transplant programme director |
| Second clinician | Reviews the evaluation and consent | Transplant 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. Evaluate.
- Evaluate the recipient against the eligibility criteria and record it (TXP-FRM-002).
Key point: Evaluated.
Step 2. Discuss.
- Discuss realistic outcomes, risks and alternatives, and allow time to consider.
Key point: Discussed.
Step 3. Consent and review.
- Record consent and have a second clinician review the file.
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 |
|---|---|---|---|---|
| Recipients with evaluation and consent recorded | 100% | Quarterly | Transplant programme director | Escalate to the 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 |
|---|---|---|
| TXP-FRM-002 | Recipient evaluation and consent record | Record |
| CON-FRM-001 | Consent record (existing) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation (2010), including the principles on donation without commercial gain, and the ASF Hospital standard for consent. |
| 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
No e-learning course is linked to this document yet.
Planned course: No e-learning course is linked to this criterion yet. A course is planned to cover it.
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)