Standards › Standard 2E › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · WRK-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2E.3
At a glance
- Wash the area at once. Do not squeeze the wound.
- Report the exposure to your line manager and occupational health the same day.
- Attend the post-exposure assessment within the time set by occupational health.
- Record the exposure on the incident system.
- Stop and get help straight away if: a staff member has a needlestick or splash, and the source patient or the staff member’s status is unknown and no one has been told.
1. Purpose
To make sure every exposure to blood or body fluid is treated at once and followed up in time [EC].
2. Scope
| Applies to | All staff, students and volunteers |
| Locations | All premises and outreach work |
| When | After any needlestick, sharps injury, or splash to eyes, nose, mouth or broken skin |
| Does not apply to | Intact skin contact with no risk |
3. Definitions
| Term | Meaning |
|---|---|
| Exposure | A percutaneous, mucosal or broken-skin contact with blood or body fluid |
| Source patient | The patient whose blood or fluid was involved |
| Post-exposure prophylaxis (PEP) | Medicine given after an exposure to reduce infection risk |
4. Background
Most exposures are preventable, but when one happens the time before treatment decides whether PEP can work. A fixed route protects the staff member.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Exposed person | Starts first aid and reports at once | Trained in first aid for exposures |
| Line manager | Makes sure the exposure is reported and the person is seen in time | Management |
| Occupational health | Assesses, offers PEP and follow-up tests | Occupational health clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Exposure first-aid kit with running water and eye wash | In every clinical area | Checked weekly |
| Exposure reporting form (incident system) | Current | Available on all wards |
7. Safety
- Do not delay first aid to report. Do not squeeze the wound. Wear gloves when cleaning.
8. Before you start
- Confirm the occupational health contact number and the out-of-hours route are on the wall of each clinical area.
9. Procedure
Step 1. Give first aid.
- Wash the area with soap and running water.
- For eyes, irrigate with clean water or saline for 15 minutes.
Key point: Do this first, before anything else.
Step 2. Report.
- Tell the line manager and occupational health the same day.
- Give the time, the cause and the source, if known.
Key point: The report starts the clock for PEP.
Step 3. Get assessed.
- Attend occupational health within the time set (usually within 2 hours for PEP).
- Ask for the source patient to be tested, with consent, where the policy allows.
Key point: PEP is most effective when started early.
Step 4. Record and learn.
- Enter the exposure on the incident system.
- Review the cause at the monthly safety meeting.
Key point: Every exposure is a learning point.
10. Decision points
- If the source is high risk, occupational health advises on PEP at once. The staff member may not defer this decision.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Use the out-of-hours number on the wall. The on-call doctor starts PEP within the time set. |
| Source patient refuses testing | Occupational health assesses the risk and advises on PEP for the staff member. |
12. Escalation
- If PEP cannot be started in time, the chief executive is informed the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Exposures reported the same day | 100% | Monthly | Occupational health lead | Escalate to chief executive |
| PEP started within the time set | 100% | Monthly | Occupational health lead | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Exposure report on the incident system | Occupational health file | Employment plus 40 years |
15. Training
- All clinical staff are trained in this procedure at induction and at each annual refresher.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-POL-003 | Occupational health, safety and wellbeing policy | Policy this procedure supports |
| WRK-SOP-003 | Staff vaccination and immunisation | Hepatitis B and other vaccinations |
17. Evidence
| Reference | Note |
|---|---|
| E-001 | WHO Guidelines on Hand Hygiene in Health Care (2009). |
| E-009 | ASF Expert Committee consensus. Time limits set by the ASF Expert Committee by occupational health. |
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)
- World Health Organization (2009). WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO. Open source (E-001)