Standards › Standard 2E › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · WRK-SOP-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2E.5
At a glance
- Assess the risk of violence for each patient on arrival or admission and at each change of condition.
- Use de-escalation first. Call for help early.
- Record every incident on the incident system the same day.
- Offer support to each staff member affected.
- Stop and get help straight away if: a staff member is at immediate risk of harm and no one has been called for help.
1. Purpose
To protect staff from violence and aggression from patients, visitors or colleagues, and to respond well when it happens [EC].
2. Scope
| Applies to | All staff, and all patients and visitors while on the premises |
| Locations | All premises and outreach work |
| When | Always; risk assessment at arrival, admission and on change of condition |
| Does not apply to | Clinical signs that are not intentional, which are managed clinically but still recorded |
3. Definitions
| Term | Meaning |
|---|---|
| Violence or aggression | Any incident in which a person is abused, threatened or assaulted at work |
| Risk assessment | A short, documented judgement of the risk a person presents to staff |
4. Background
Violence against health workers is common and under-reported. Staff who feel protected report more and stay longer. This procedure makes protection concrete.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Service manager | Makes sure risk assessments are done and staff are trained | Management |
| Clinical staff | Assess risk, use de-escalation and record incidents | Trained in de-escalation |
| Security lead | Responds to serious incidents and advises on premises | Security |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Violence and aggression incident record (WRK-FRM-003) | Current | On the incident system |
| Alarm or call system | In every consulting and treatment room | Tested monthly |
7. Safety
- Never put yourself at risk to protect property. Leave the room if your safety is at risk, and call for help.
8. Before you start
- Confirm the alarm works in the area and staff know how to call.
9. Procedure
Step 1. Assess risk.
- Assess the person’s history, mood and behaviour on arrival.
- Record the risk level and any warning signs.
Key point: The assessment is done before, not after, the incident.
Step 2. De-escalate.
- Speak calmly, keep distance and give the person choices.
- Use a second member of staff if available.
Key point: Early calling for help is part of the procedure, not a failure.
Step 3. Call for help.
- Use the alarm or call the security lead.
- Move other people away from the area.
Key point: Call early.
Step 4. Record and support.
- Complete WRK-FRM-003 the same day.
- Offer support to each person affected, using WRK-SOP-004.
Key point: Every incident is recorded, even if no one was hurt.
10. Decision points
- If a patient continues to threaten staff, the clinical lead decides on restriction or transfer, with reasons recorded and a review time set.
11. Special situations
| Situation | Action |
|---|---|
| Weapon present | Leave the area and call the security lead and the police at once. |
| Visitor aggression | Ask the visitor to leave, then call security if they do not comply. |
12. Escalation
- Any serious assault is reported to the chief executive and to the police, where the staff member wishes, the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Incidents recorded the same day | 100% | Monthly | Service manager | Escalate to chief executive |
| Staff affected offered support | 100% | Monthly | Occupational health lead | Escalate to chief executive |
| Risk assessments done for patients on arrival | At least 70% | Monthly | Service manager | Retrain the team |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| WRK-FRM-003 Violence and aggression incident record | Incident system and occupational health file | Employment plus 6 years |
15. Training
- All clinical staff are trained in de-escalation and this procedure at induction, and refreshed each year.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-FRM-003 | Violence and aggression incident record | Record used in step 4 |
| WRK-SOP-004 | Support after distressing events | Support after incidents |
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 |
E-learning for this document
No e-learning course is linked to this document yet.
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)