Standards › ASF Health Standards V11 › Standard 7
Standard 7 (Surgical and Procedural Safety), PDF
ASF-HS11-S07 · 1 November 2026 · 25 pages, A4. The same criteria as this page, for printing and assessors.
Where this standard applies
Standard 7 applies to facilities that perform surgical or other invasive procedures: hospitals, ambulatory clinics and dental clinics. It is marked N/A for the other facility types. The table shows each criterion by facility type.
| Criterion | Hospital | Ambulatory clinic | Primary health clinic | Long-term care | Telemedicine | Home care | Fitness and wellness | Dental clinic | Aesthetic and procedure clinic |
|---|---|---|---|---|---|---|---|---|---|
| 7.1 The Surgical Safety Checklist Is Used | Yes | Yes | N/A | N/A | N/A | N/A | N/A | Yes | N/A |
| 7.2 Anaesthesia Is Delivered Safely | Yes | Yes | N/A | N/A | N/A | N/A | N/A | Yes | N/A |
| 7.3 Surgical Site Infection Is Actively Prevented | Yes | Yes | N/A | N/A | N/A | N/A | N/A | Yes | N/A |
| 7.4 Procedures Are Performed Within Granted Privileges and Marked Correctly | Yes | Yes | N/A | N/A | N/A | N/A | N/A | Yes | N/A |
| 7.5 Post-Operative Monitoring and Recovery Are Safe | Yes | Yes | N/A | N/A | N/A | N/A | N/A | Yes | N/A |
| 7.6 Instrument, Swab and Sharps Counts Are Completed | Yes | Yes | N/A | N/A | N/A | N/A | N/A | Yes | N/A |
Surgical and Procedural Safety
Surgical and procedural care is made safe through the surgical safety checklist, safe anaesthesia, prevention of surgical site infection, procedures performed within privileges, safe recovery and complete instrument, swab and sharps counts.
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
7.1
The Surgical Safety Checklist Is Used
Humanitarian settings: MustTransition and fragile: MustStandard: Must
The WHO Surgical Safety Checklist is completed out loud, as a team, at three pauses: before induction of anaesthesia, before skin incision, and before the patient leaves the operating room.
Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: primary health clinic, long-term care, telemedicine, home care, fitness and wellness, aesthetic and procedure clinic.
Why it matters. The checklist works only when the team says it out loud at each pause. A checklist completed after the operation protects no one.
Questions the surveyor asks
- Is the checklist completed out loud at all three pauses? Sign-in, time-out and sign-out, not just one of them.
- Does every team member take part? A checklist read by one person to a silent room misses its purpose.
- Is there evidence that the checklist has changed a decision or caught an issue? A checklist that never catches anything is worth questioning, not just checking for completion.
How the surveyor verifies this criterion
Sample. Observation of 10 procedures across two weeks, and the completed checklist records for the last 3 months.
1. Three pauses done out loud
Method. Observe 10 procedures and note each pause.
Evidence to show. Completed checklist record (SRG-FRM-001) and an observation record.
Pass when. All three pauses are completed out loud in at least 9 of the 10 observed procedures.
2. Team takes part
Method. Observe who responds at each pause.
Evidence to show. Observation record.
Pass when. At least the surgeon, anaesthetist and nurse respond at each pause.
3. Records are complete
Method. Check the last 3 months of checklist records.
Evidence to show. Completed SRG-FRM-001 records.
Pass when. Every record is signed by the team leader at all three pauses.
Immediate fail (any one means the criterion is not met)
- The checklist is signed after the operation with no pause during the procedure.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. The checklist is spoken out loud at all three pauses, with the whole team taking part.
Partial because. The three pauses are held, but not every team member takes part, or a pause is sometimes missed, or some records are not signed at all three pauses.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Surgeon or designated team leader ISCO 2212 ASF proposal |
Leads the procedure, pauses the team and decides on any count mismatch. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Safe Surgery: Correct Site, Procedure, Patient (PS-04) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-001 SRG-SOP-001 |
| Anaesthetist ISCO 2212 ASF proposal |
Takes part in the pauses and in the anaesthesia and count decisions. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Safe Surgery: Correct Site, Procedure, Patient (PS-04) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-001 SRG-SOP-001 |
| Theatre nurse ISCO 2221 ASF proposal |
Counts, records and checks the equipment and the record for each case. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Safe Surgery: Correct Site, Procedure, Patient (PS-04) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-001 SRG-SOP-001 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Ophthalmology & Day Surgery Safety (AMB-15) GMJ Academy: English · Georgian |
Theatre team | None |
| WHO Surgical Safety Checklist and team pause, for field teams (FLD-03) GMJ Academy: English · Georgian |
None | Field teams |
| Safe Surgery: Correct Site, Procedure, Patient (PS-04) GMJ Academy: English · Georgian |
Theatre team | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| SRG-FRM-001 · Surgical safety checklist record Form (record) · The WHO surgical safety checklist for one procedure, completed aloud at sign-in, time-out and sign-out. |
Theatre team | Clinical lead (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-POL-001 · Surgical safety checklist and team pause Policy · To make sure the team confirms the right patient, the right procedure and the right site together, at each pause. |
Quality lead (ISCO 1342) | Chief executive (ISCO 1120) | Clinical lead (ISCO 1342) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-SOP-001 · Surgical safety checklist procedure Procedure (SOP) · To run the checklist the same way in every theatre, every time. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2009). Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Used for: the surgical safety checklist and its three pauses (7.1). https://news.gmj.ge/guideline/guidelines-for-safe-surgery-2009-safe-surgery-saves-lives/
7.2
Anaesthesia Is Delivered Safely
Humanitarian settings: MustTransition and fragile: MustStandard: Must
Anaesthesia follows a written safety protocol, with monitoring throughout the procedure matched to the level of anaesthesia and the patient's risk.
Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: primary health clinic, long-term care, telemedicine, home care, fitness and wellness, aesthetic and procedure clinic.
Why it matters. Anaesthesia is the highest-risk part of many procedures. Continuous monitoring through the whole procedure finds problems early, while there is still time to act.
Questions the surveyor asks
- Is monitoring continued through the whole procedure, including emergence? Gaps in the middle of a long procedure are a documented risk pattern.
- Is the equipment present, working and checked before use? Equipment that is present but not checked gives false reassurance.
- Is there an escalation protocol for anaesthesia complications? A protocol for a routine case is not the same as a protocol for when something goes wrong.
How the surveyor verifies this criterion
Sample. Ten anaesthesia records from the last 3 months, and the anaesthesia machine check log for the same days.
1. Monitoring is recorded throughout
Method. Check each record for monitoring entries at induction, during the procedure and at emergence.
Evidence to show. Anaesthesia record and monitoring chart (SRG-FRM-002).
Pass when. Monitoring is recorded at least every 5 minutes in all sampled records.
2. Equipment is checked before each list
Method. Check the machine check log for each sampled day.
Evidence to show. Anaesthesia machine and equipment check (SRG-FRM-003).
Pass when. A completed check is recorded before the first case of each sampled day.
3. Escalation is known
Method. Ask an anaesthetist and a nurse to explain the steps for a sudden fall in oxygen saturation.
Evidence to show. Anaesthesia safety and monitoring policy (SRG-POL-002).
Pass when. Both describe the same steps, and the steps match the policy.
Immediate fail (any one means the criterion is not met)
- A ventilated or sedated patient is monitored with alarms switched off or with no monitoring recorded.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Monitoring recorded at least every 5 minutes, with the equipment checked before each list.
Partial because. Monitoring is recorded at irregular intervals, or the equipment is checked but the log is not completed.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Surgeon or designated team leader ISCO 2212 ASF proposal |
Leads the procedure, pauses the team and decides on any count mismatch. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Safe Anaesthesia and Sedation (PS-13) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-002 SRG-FRM-003 AES-SOP-003 DAY-SOP-002 |
| Anaesthetist ISCO 2212 ASF proposal |
Takes part in the pauses and in the anaesthesia and count decisions. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Safe Anaesthesia and Sedation (PS-13) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-002 SRG-FRM-003 AES-SOP-003 DAY-SOP-002 |
| Theatre nurse ISCO 2221 ASF proposal |
Counts, records and checks the equipment and the record for each case. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Safe Anaesthesia and Sedation (PS-13) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-002 SRG-FRM-003 AES-SOP-003 DAY-SOP-002 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Ophthalmology & Day Surgery Safety (AMB-15) GMJ Academy: English · Georgian |
Theatre team | None |
| Safe Anaesthesia and Sedation (PS-13) GMJ Academy: English · Georgian |
Theatre team | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| SRG-FRM-002 · Anaesthesia record and monitoring chart Form (record) · Records the anaesthesia and the monitoring of the patient from induction to recovery. |
Theatre team | Clinical lead (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-FRM-003 · Anaesthesia machine and equipment check Form (record) · The daily check of the anaesthetic machine, monitors, suction and emergency airway equipment before the first case. |
Theatre team | Clinical lead (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-POL-002 · Anaesthesia safety and monitoring Policy · To keep the patient safe throughout anaesthesia, with monitoring matched to their risk. |
Quality lead (ISCO 1342) | Chief executive (ISCO 1120) | Clinical lead (ISCO 1342) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| AES-SOP-003 · Sedation and anaesthesia safety Procedure (SOP) · To keep patients safe during sedation and anaesthesia in an aesthetic setting. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| DAY-SOP-002 · Sedation and anaesthesia level, and response to complications Procedure (SOP) · To match the level of sedation to the staff, the monitoring and the response available. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2009). Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Used for: safe anaesthesia and monitoring during the procedure (7.2). https://news.gmj.ge/guideline/guidelines-for-safe-surgery-2009-safe-surgery-saves-lives/
- World Health Organization. Anaesthesia at the district hospital, second edition. Used for: anaesthesia practice and equipment checks where resources are limited (7.2). https://news.gmj.ge/guideline/anaesthesia-at-the-district-hospital/
7.3
Surgical Site Infection Is Actively Prevented
Humanitarian settings: MediumTransition and fragile: MediumStandard: Must
The surgical site infection (SSI) prevention bundle is applied to every procedure: antibiotic prophylaxis given at the right time, skin preparation with an approved antiseptic, hair removed only when it would interfere with surgery, normal body temperature and blood glucose control.
Rating: Medium in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: primary health clinic, long-term care, telemedicine, home care, fitness and wellness, aesthetic and procedure clinic.
Why it matters. Surgical site infection is one of the most common complications of surgery. Most cases can be prevented with a short set of measures applied every time.
Questions the surveyor asks
- Is antibiotic prophylaxis given within the recommended window before incision? Timing matters as much as the choice of drug.
- Is the skin prepared with an approved antiseptic, and is hair removed only when needed? Routine shaving increases the risk of infection.
- Are surgical site infections recorded and reviewed? A rate that is not known cannot be improved.
How the surveyor verifies this criterion
Sample. Twenty procedures from the last 3 months, with the bundle record and the infection log.
1. Bundle recorded for each procedure
Method. Check the bundle record for each sampled procedure.
Evidence to show. SSI bundle compliance record (SRG-FRM-004).
Pass when. The bundle is recorded for at least 18 of 20 sampled procedures.
2. Antibiotic given on time
Method. Compare the time of the antibiotic dose with the time of incision.
Evidence to show. Anaesthesia record (SRG-FRM-002).
Pass when. Given within the window in SRG-SOP-003 in at least 18 of 20 procedures.
3. Infections are reviewed
Method. Check the infection log and the review minutes for the last 3 months.
Evidence to show. SSI log and review minutes.
Pass when. Every infection is logged and reviewed at least every quarter.
Immediate fail (any one means the criterion is not met)
- No surveillance of surgical site infections is in place.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. The bundle is recorded, antibiotic timing is checked, and infections are reviewed every quarter.
Partial because. The bundle is used but not recorded, antibiotic timing is not checked, or surveillance is done only once a year.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Surgeon or designated team leader ISCO 2212 ASF proposal |
Leads the procedure, pauses the team and decides on any count mismatch. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Surgical Site Infection Prevention (PS-15) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-004 SRG-FRM-002 SRG-SOP-003 SRG-SOP-002 HH-SOP-001 |
| Anaesthetist ISCO 2212 ASF proposal |
Takes part in the pauses and in the anaesthesia and count decisions. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Surgical Site Infection Prevention (PS-15) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-004 SRG-FRM-002 SRG-SOP-003 SRG-SOP-002 HH-SOP-001 |
| Theatre nurse ISCO 2221 ASF proposal |
Counts, records and checks the equipment and the record for each case. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Surgical Site Infection Prevention (PS-15) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-004 SRG-FRM-002 SRG-SOP-003 SRG-SOP-002 HH-SOP-001 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Ophthalmology & Day Surgery Safety (AMB-15) GMJ Academy: English · Georgian |
Theatre team | None |
| Surgical Site Infection Prevention (PS-15) GMJ Academy: English · Georgian |
Theatre team | None |
| Sterilization, Disinfection and Reprocessing (PS-07) GMJ Academy: English · Georgian |
None | Theatre team |
| Infection Prevention and Control Essentials (BAS-05) GMJ Academy: English · Georgian |
None | Theatre team |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| SRG-FRM-004 · Surgical site infection bundle compliance record Form (record) · Records, for each procedure, whether each part of the bundle was done. |
Theatre team | Clinical lead (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-FRM-002 · Anaesthesia record and monitoring chart Form (record) · Records the anaesthesia and the monitoring of the patient from induction to recovery. |
Theatre team | Clinical lead (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-POL-003 · Surgical site infection prevention Policy · To prevent surgical site infections with a set of practices that can be checked. |
Quality lead (ISCO 1342) | Chief executive (ISCO 1120) | Clinical lead (ISCO 1342) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-SOP-003 · Surgical site infection prevention bundle Procedure (SOP) · To apply the bundle the same way for every procedure. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-SOP-002 · Surgical site marking and patient identification before every operation Procedure (SOP) · To make sure the correct patient has the correct procedure on the correct site, by marking the site before the patient goes to theatre and by checking the mark and the identity at the sign-in and time-out pauses. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HH-SOP-001 · Hand hygiene at the point of care Procedure (SOP) |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| IPC-POL-001 · Infection prevention and control programme Policy · To prevent healthcare-associated infection to patients, staff and visitors through a written, reviewed and monitored programme (B1.15). |
Quality lead (ISCO 1342) | Chief executive (ISCO 1120) | Clinical lead (ISCO 1342) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2018). Global guidelines for the prevention of surgical site infection, second edition. Used for: the measures that prevent surgical site infection (7.3). https://news.gmj.ge/guideline/global-guidelines-for-the-prevention-of-surgical-site-infection-second-edition/
- World Health Organization. Implementation manual to support the prevention of surgical site infections at the facility level. Used for: putting the prevention measures into practice in a facility (7.3). https://news.gmj.ge/guideline/implementation-manual-to-support-the-prevention-of-surgical-site-infections-at-the-facility-level-turning-recommendations-into-practice/
7.4
Procedures Are Performed Within Granted Privileges and Marked Correctly
Humanitarian settings: MediumTransition and fragile: MustStandard: Must
Each surgeon operates only within the privileges granted by the facility. The operating list is checked against those privileges before the day starts, and the operative site is marked and verified before every operation.
Rating: Medium in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: primary health clinic, long-term care, telemedicine, home care, fitness and wellness, aesthetic and procedure clinic.
Why it matters. Wrong-site, wrong-procedure and operations by staff without the right training are among the most serious patient safety events. Clear privileges and site marking prevent them.
Questions the surveyor asks
- Does each surgeon have a current privilege list? A verbal assurance is not evidence.
- Is the operating list checked against privileges before the day starts? A procedure found outside privileges in the middle of an operation is a serious risk.
- Is the operative site marked and verified for laterality and multi-level procedures? Confirming the procedure name alone does not rule out a wrong-site error.
How the surveyor verifies this criterion
Sample. The privilege list for all operating surgeons, the operating lists for 10 days, and site-marking records for 15 procedures.
1. Each surgeon has current privileges
Method. Check the privilege list against each surgeon's file.
Evidence to show. Surgeon privileges and operating list check (SSC-SOP-001).
Pass when. Every operating surgeon has a privilege entry that has not expired.
2. Operating lists are checked
Method. Check each sampled operating list against the privilege list.
Evidence to show. Signed operating list check (SSC-SOP-001).
Pass when. All sampled lists are checked before the first case.
3. Site is marked and verified
Method. Check the records for 15 procedures involving laterality or several levels.
Evidence to show. Surgical site marking record (SRG-SOP-002).
Pass when. The site is marked and verified at the time-out in every sampled procedure.
Immediate fail (any one means the criterion is not met)
- An operation is performed outside the surgeon's granted privileges.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Privileges are reviewed every year, the list check is signed at the start of the day, and the site is marked and checked out loud.
Partial because. Privileges exist but are not reviewed, or the list is checked verbally but not signed.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Surgeon or designated team leader ISCO 2212 ASF proposal |
Leads the procedure, pauses the team and decides on any count mismatch. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Safe Surgery: Correct Site, Procedure, Patient (PS-04) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SSC-SOP-001 SRG-SOP-002 |
| Anaesthetist ISCO 2212 ASF proposal |
Takes part in the pauses and in the anaesthesia and count decisions. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Safe Surgery: Correct Site, Procedure, Patient (PS-04) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SSC-SOP-001 SRG-SOP-002 |
| Theatre nurse ISCO 2221 ASF proposal |
Counts, records and checks the equipment and the record for each case. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Safe Surgery: Correct Site, Procedure, Patient (PS-04) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SSC-SOP-001 SRG-SOP-002 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Ophthalmology & Day Surgery Safety (AMB-15) GMJ Academy: English · Georgian |
Theatre team | None |
| Safe Surgery: Correct Site, Procedure, Patient (PS-04) GMJ Academy: English · Georgian |
Theatre team | None |
| Credentialing, Competence and the Training Matrix (T-14) GMJ Academy: English · Georgian |
None | Clinical lead, Medical director |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| SSC-SOP-001 · Surgeon privileges and operating list check Procedure (SOP) · To make sure surgeons operate only within their granted privileges. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-SOP-002 · Surgical site marking and patient identification before every operation Procedure (SOP) · To make sure the correct patient has the correct procedure on the correct site, by marking the site before the patient goes to theatre and by checking the mark and the identity at the sign-in and time-out pauses. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2009). Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Used for: operating on the correct patient at the correct site (7.4). https://news.gmj.ge/guideline/guidelines-for-safe-surgery-2009-safe-surgery-saves-lives/
- World Health Organization (2007). WHO Nine Patient Safety Solutions. Used for: performance of the correct procedure at the correct body site (7.4). https://news.gmj.ge/guideline/who-nine-patient-safety-solutions-2007/
7.5
Post-Operative Monitoring and Recovery Are Safe
Humanitarian settings: MediumTransition and fragile: MustStandard: Must
Patients are monitored after surgery in a recovery area by trained staff, with written discharge criteria. Any deterioration triggers a defined response.
Rating: Medium in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: primary health clinic, long-term care, telemedicine, home care, fitness and wellness, aesthetic and procedure clinic.
Why it matters. Many post-operative complications, such as bleeding, respiratory depression and sepsis, appear after the patient has left the operating room. A defined recovery and discharge standard catches them in time.
Questions the surveyor asks
- Is there a recovery area with monitoring and trained staff? Recovery is part of the procedure, not an afterthought.
- Are discharge criteria written and applied to every patient? Discharge before the criteria are met is a documented risk.
- Does every patient or escort receive written advice? Verbal advice alone is easy to forget.
How the surveyor verifies this criterion
Sample. Fifteen recovery records and fifteen discharge records from the last 3 months.
1. Recovery monitoring is recorded
Method. Check the observations in each recovery record.
Evidence to show. Recovery monitoring and discharge criteria record (DAY-SOP-001).
Pass when. Observations are recorded at the intervals in DAY-SOP-001 in all sampled records.
2. Discharge criteria are met
Method. Check each discharge record against the criteria.
Evidence to show. Recovery monitoring and discharge criteria (DAY-SOP-001).
Pass when. All sampled discharges meet the criteria, or have a documented senior review.
3. Written advice is given
Method. Check the advice record for each sampled patient.
Evidence to show. Escort and written discharge advice (DAY-POL-002).
Pass when. Written advice is given to every sampled patient or escort.
Immediate fail (any one means the criterion is not met)
- A patient is discharged with no recovery monitoring at all.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Observations at the defined intervals, and a discharge checklist signed for every patient.
Partial because. Recovery is observed but not recorded, or advice is given verbally only.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Surgeon or designated team leader ISCO 2212 ASF proposal |
Leads the procedure, pauses the team and decides on any count mismatch. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Recognising and Responding to the Deteriorating Patient (PS-12) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
DAY-SOP-001 DAY-SOP-004 DAY-SOP-002 |
| Anaesthetist ISCO 2212 ASF proposal |
Takes part in the pauses and in the anaesthesia and count decisions. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Recognising and Responding to the Deteriorating Patient (PS-12) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
DAY-SOP-001 DAY-SOP-004 DAY-SOP-002 |
| Theatre nurse ISCO 2221 ASF proposal |
Counts, records and checks the equipment and the record for each case. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Recognising and Responding to the Deteriorating Patient (PS-12) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
DAY-SOP-001 DAY-SOP-004 DAY-SOP-002 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Ophthalmology & Day Surgery Safety (AMB-15) GMJ Academy: English · Georgian |
Theatre team | None |
| Recognising and Responding to the Deteriorating Patient (PS-12) GMJ Academy: English · Georgian |
Theatre team | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| DAY-SOP-001 · Recovery monitoring and discharge criteria Procedure (SOP) · To keep patients safe in the hour after anaesthesia, when risk is highest. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| DAY-POL-002 · Escort and written discharge advice Policy · To make sure no patient goes home after anaesthesia alone, and that they know what to watch for. |
Quality lead (ISCO 1342) | Chief executive (ISCO 1120) | Clinical lead (ISCO 1342) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| DAY-SOP-004 · Pre-procedure checks for day surgery Procedure (SOP) · To catch the errors that the pre-procedure checks find before the patient is anaesthetised. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| DAY-SOP-002 · Sedation and anaesthesia level, and response to complications Procedure (SOP) · To match the level of sedation to the staff, the monitoring and the response available. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- Association of Anaesthetists of Great Britain and Ireland (2013). Immediate Post-anaesthesia Recovery 2013. Used for: monitoring and staffing in the recovery area (7.5). https://news.gmj.ge/guideline/immediate-post-anaesthesia-recovery-2013/
- Association of Anaesthetists and British Association of Day Surgery (2019). Guidelines for Day-Case Surgery. Used for: discharge criteria and written advice after day surgery (7.5). https://news.gmj.ge/guideline/aoa-bads-guidelines-for-day-case-surgery-2019/
7.6
Instrument, Swab and Sharps Counts Are Completed
Humanitarian settings: MustTransition and fragile: MustStandard: Must
Instruments, swabs and sharps are counted before the procedure starts, before the wound is closed and before the patient leaves the operating room. Any mismatch is investigated before the team moves on.
Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: primary health clinic, long-term care, telemedicine, home care, fitness and wellness, aesthetic and procedure clinic.
Why it matters. Retained surgical items are a serious and preventable harm. A count that is not done, or is done but not recorded, gives no protection.
Questions the surveyor asks
- Are counts done at all three points? Before the procedure, before closure, and before the patient leaves.
- Is there a record that matches the count? A count that is not written down cannot be checked.
- What happens when a count does not match? The team stops and searches before the patient leaves the operating room.
How the surveyor verifies this criterion
Sample. Count records for 20 procedures from the last 3 months, and the incident log for count mismatches.
1. Counts are recorded at each point
Method. Check the count record for each sampled procedure.
Evidence to show. Instrument, swab and sharps count record (SRG-FRM-005).
Pass when. All three counts are recorded in at least 19 of the 20 sampled procedures.
2. Mismatches are investigated
Method. Check the incident log for any count mismatch.
Evidence to show. Incident log entries and their resolution.
Pass when. Every mismatch is recorded and resolved before the patient leaves the operating room.
3. Sharps are disposed of safely
Method. Observe the disposal of sharps in 5 procedures.
Evidence to show. Sharps and clinical waste management (WST-SOP-001).
Pass when. Sharps are placed straight into puncture-proof containers.
Immediate fail (any one means the criterion is not met)
- A patient leaves the operating room with a count that has not been reconciled.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Counts recorded at all three points, with any mismatch resolved before closure.
Partial because. Counts are done but not recorded.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Surgeon or designated team leader ISCO 2212 ASF proposal |
Leads the procedure, pauses the team and decides on any count mismatch. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Sharps and Clinical Waste Handling (BAS-02) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-005 WST-SOP-001 SRG-SOP-001 SRG-SOP-004 |
| Anaesthetist ISCO 2212 ASF proposal |
Takes part in the pauses and in the anaesthesia and count decisions. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Sharps and Clinical Waste Handling (BAS-02) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-005 WST-SOP-001 SRG-SOP-001 SRG-SOP-004 |
| Theatre nurse ISCO 2221 ASF proposal |
Counts, records and checks the equipment and the record for each case. | Humanitarian: Essential Transition: Essential Standard: Essential |
Ophthalmology & Day Surgery Safety (AMB-15) Sharps and Clinical Waste Handling (BAS-02) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
SRG-FRM-005 WST-SOP-001 SRG-SOP-001 SRG-SOP-004 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Ophthalmology & Day Surgery Safety (AMB-15) GMJ Academy: English · Georgian |
Theatre team | None |
| Sharps and Clinical Waste Handling (BAS-02) GMJ Academy: English · Georgian |
Theatre team | None |
| Safe Surgery: Correct Site, Procedure, Patient (PS-04) GMJ Academy: English · Georgian |
None | Theatre team |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| SRG-FRM-005 · Instrument, swab and sharps count record Form (record) |
Theatre team | Clinical lead (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| WST-SOP-001 · Sharps and clinical waste management Procedure (SOP) |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-SOP-001 · Surgical safety checklist procedure Procedure (SOP) · To run the checklist the same way in every theatre, every time. |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| SRG-SOP-004 · Instrument, swab and sharps count procedure Procedure (SOP) |
Clinical lead (ISCO 1342) | Medical director (ISCO 1342) | Theatre team | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2009). Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Used for: preventing retained instruments and swabs (7.6). https://news.gmj.ge/guideline/guidelines-for-safe-surgery-2009-safe-surgery-saves-lives/
Role details: reporting, supervision and training
Each role links to its own terms of reference, which holds the full reporting line, supervision, training and competency record.
Who is responsible for Standard 7
Each criterion below names the positions responsible for it.
| Criterion | Positions responsible or involved | |
|---|---|---|
| 7.1 | The Surgical Safety Checklist Is Used | Surgeon or designated team leader · Anaesthetist · Theatre nurse |
| 7.2 | Anaesthesia Is Delivered Safely | Surgeon or designated team leader · Anaesthetist · Theatre nurse |
| 7.3 | Surgical Site Infection Is Actively Prevented | Surgeon or designated team leader · Anaesthetist · Theatre nurse |
| 7.4 | Procedures Are Performed Within Granted Privileges and Marked Correctly | Surgeon or designated team leader · Anaesthetist · Theatre nurse |
| 7.5 | Post-Operative Monitoring and Recovery Are Safe | Surgeon or designated team leader · Anaesthetist · Theatre nurse |
| 7.6 | Instrument, Swab and Sharps Counts Are Completed | Surgeon or designated team leader · Anaesthetist · Theatre nurse |
Quality oversight
The quality chain keeps this standard under review, from the governing body down to the teams that run each process.
Related courses in the GMJ Academy
These courses cover the same subjects in more depth or for a specific type of facility. They are optional. They are not required by the criteria.
| Course | Subject |
|---|---|
| Safe Surgery: Correct Site, Procedure, Patient (PS-04) GMJ Academy: https://academy.gmj.ge/course-search/safe-surgery-correct-site-procedure-patient-en/ |
Correct site, procedure and patient checks |
| Safe Anaesthesia and Sedation (PS-13) GMJ Academy: https://academy.gmj.ge/course-search/safe-anaesthesia-sedation-en/ |
Safe anaesthesia and sedation |
| Surgical Site Infection Prevention (PS-15) GMJ Academy: https://academy.gmj.ge/course-search/surgical-site-infection-prevention-en/ |
Surgical site infection prevention |
| WHO Surgical Safety Checklist for Field Teams (FLD-03) GMJ Academy: https://academy.gmj.ge/course-search/asf-fld-03-en/ |
WHO surgical safety checklist in practice |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 7 apply to?
Facilities that perform surgical or other invasive procedures. The table at the top of this page shows each criterion by facility type: all six criteria apply to hospitals, ambulatory clinics and dental clinics, and are marked N/A for the other six facility types. Each criterion has its own pass rule and its own immediate-fail rule, so each one must be met on its own.
What is an immediate fail?
An immediate fail is one event or finding that means a criterion is not met, even if everything else in that criterion is in place. For example, if a patient leaves the operating room with a count that has not been reconciled, criterion 7.6 fails outright, however complete the other records are. Each criterion on this page lists its own immediate fail under “Immediate fail”. Facilities should read these before the survey, because they are the points on which the outcome is decided most quickly.
Which documents do I submit?
The documents are the policies, procedures and forms listed under each criterion in the “Documents: who does each step” table. Forms, such as the Surgical safety checklist record (SRG-FRM-001) or the Instrument, swab and sharps count record (SRG-FRM-005), are completed for each procedure and kept as evidence. Policies and procedures are signed documents that show the version, date, owner and approver. Have the records ready for the period stated in each criterion, which is the last 3 months for most checks. You may use your own document if it meets the same check, as long as it is clearly the same record.
Are the ratings the same in every setting?
No. Three criteria are Must in every setting, including humanitarian settings, because they protect life directly: the surgical safety checklist (7.1), safe anaesthesia (7.2) and the counts (7.6). Privileges and site marking (7.4) and recovery (7.5) are Medium in humanitarian settings and Must in transition and fragile and in standard settings. Prevention of surgical site infection (7.3) is Medium in humanitarian and in transition and fragile settings, and Must in standard settings.
Must every operation have a completed surgical safety checklist?
Yes, and it must be completed out loud by the team at three pauses: before induction of anaesthesia, before skin incision, and before the patient leaves the operating room. The surveyor observes 10 procedures across two weeks and expects all three pauses to be spoken in at least 9 of them, with at least the surgeon, the anaesthetist and the nurse responding at each pause. The surveyor also checks the last 3 months of completed checklist records (SRG-FRM-001), each signed by the team leader at all three pauses. A checklist signed after the operation, with no pause during the procedure, is an immediate fail.
Must a patient be monitored throughout anaesthesia?
Yes. Monitoring must be recorded from induction, through the procedure, to emergence, at least every 5 minutes, on the Anaesthesia record and monitoring chart (SRG-FRM-002). The anaesthetic machine and equipment must be checked before the first case of each day, and the check recorded (SRG-FRM-003). The surveyor reviews ten anaesthesia records from the last 3 months and asks an anaesthetist and a nurse to explain the steps for a sudden fall in oxygen saturation; both should describe the same steps, and the steps should match the policy (SRG-POL-002). A ventilated or sedated patient with alarms switched off, or with no monitoring recorded, is an immediate fail.
What is the surgical site infection bundle, and how is it checked?
It is a short set of measures applied to every procedure: antibiotic prophylaxis given at the right time, skin preparation with an approved antiseptic, hair removed only when it would interfere with surgery, and normal body temperature and blood glucose control. The surveyor takes twenty procedures from the last 3 months and expects the bundle to be recorded for at least 18 of them (SRG-FRM-004), with the antibiotic given within the window set in the bundle procedure (SRG-SOP-003) in at least 18. Every infection must be logged and reviewed at least every quarter. A facility with no surveillance of surgical site infections fails the criterion immediately.
How are privileges and site marking checked?
Each surgeon may operate only within the privileges the facility has granted. The surveyor checks that every operating surgeon has a privilege entry that has not expired, that the operating lists for 10 days were checked against the privileges before the first case (SSC-SOP-001), and that the site was marked and verified at the time-out in 15 procedures involving a side of the body or several levels (SRG-SOP-002). An operation performed outside the surgeon’s granted privileges is an immediate fail.
Must a discharged patient have written advice?
Yes. After surgery the patient is monitored in a recovery area by trained staff, with observations at the intervals set in the recovery procedure (DAY-SOP-001). Discharge follows written criteria, or a documented senior review where the criteria are not fully met. Every patient or escort receives written advice (DAY-POL-002), because spoken advice alone is easy to forget. The surveyor reviews fifteen recovery records and fifteen discharge records from the last 3 months. Discharging a patient with no recovery monitoring at all is an immediate fail.
What happens when a count does not match?
The team stops and searches before the patient leaves the operating room. Instruments, swabs and sharps are counted at three points: before the procedure starts, before the wound is closed, and before the patient leaves. The surveyor checks the count records for 20 procedures (SRG-FRM-005) and expects all three counts in at least 19, and checks the incident log to see that every mismatch was recorded and resolved before the patient left. The surveyor also observes sharps disposal in 5 procedures: sharps go straight into puncture-proof containers (WST-SOP-001).
What do the colours mean?
Red means Must: the criterion is required in every setting, and criteria that protect life are always red. Yellow means Medium: the criterion is required, but adapted to what a transition setting can realistically do. Green means Minimum: the lowest acceptable level in a humanitarian setting, where resources are very limited. In standard settings every criterion is Must. Each criterion shows its rating for each of the three settings, so a facility can see exactly what applies to it.
Do we have to use your forms and policies?
No. Every policy, procedure, form and course on this page is a reference draft to help you meet the criterion. You can adapt it to your facility, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how. If you use your own document, make sure it covers the same content as the reference and that it is current, signed and dated, so that the assessor can match it to the criterion without difficulty.
What does essential or recommended training mean for my staff?
In the training tables, red means essential: the course is required for that role in that setting. Green means recommended: the course is advised for that role. Yellow means optional. Each course shows its level for humanitarian, transition and fragile, and standard settings, because the requirement can differ between them. Staff evidence is a verified micro-credential in the GMJ Academy micro-credential portfolio, or a training certificate kept in the staff file.
Do we have to use ISCO-08 codes?
The staff tables give each occupation its ISCO-08 code, so that roles can be compared between facilities and countries. You are not required to change your job titles. What matters is that each role named in the standard can be matched to the person who does that job and to the training they have had. If your titles differ, record the match in your staff file so that the assessor can follow it.
Which training do staff need?
The e-learning table under each criterion shows who must take each course and who is recommended. The theatre team takes the course that matches each criterion: Safe Surgery: Correct Site, Procedure, Patient for the checklist and for site marking, Safe Anaesthesia and Sedation, Surgical Site Infection Prevention, Recognising and Responding to the Deteriorating Patient for recovery, and Sharps and Clinical Waste Handling for the counts, together with Ophthalmology & Day Surgery Safety. Each course name opens the course page in the GMJ Academy. Staff can show evidence through a verified micro-credential in the GMJ Academy micro-credential portfolio, or through a training certificate kept in the staff file.
What will the surveyor see on the day?
The surveyor works through the criteria, following the “Sample” and the checks given for each one. Standard 7 is checked both by watching and by reading. The surveyor observes procedures, to see the three checklist pauses and the disposal of sharps, and asks the team questions, for example what happens when a count does not match. The surveyor also reviews records from the last 3 months: checklist records, anaesthesia records and machine checks, bundle records and the infection log, privilege lists and operating lists, recovery and discharge records, and count records.
How does the surveyor choose which records to check?
Each criterion states its own sample, such as “Ten anaesthesia records from the last 3 months, and the anaesthesia machine check log for the same days” or “Count records for 20 procedures from the last 3 months, and the incident log for count mismatches”. The surveyor uses the sample given on the criterion rather than choosing records to suit the facility. Preparing for the survey means keeping the records for the whole period stated, organised so that any item in the sample can be produced quickly. A facility that cannot produce the sampled records loses the criterion, whatever else it has in place.
What if we do not have the written protocol yet?
A criterion cannot be met on the basis of an unwritten or informal arrangement, because the assessor needs something to check against. If a protocol does not yet exist, write one before the survey, using the reference draft or your own version, and make sure it is signed, dated and in use. Staff must be able to explain it in practice.
Where can I get the full text?
The full text of each criterion, with its rating, why it matters, the assessor checks, the immediate-fail rule and the documents, is on this page. A PDF with the same criteria, for printing and for assessors, can be downloaded from the box at the top of this page. The questions and answers on this page summarise the criteria, and if they ever differ, the criterion text is the authority.
Who can I ask about this standard?
For questions about this standard, contact Accréditation Sans Frontières through the Contact page of this website. Please give the standard number and the criterion (for example 7.3) so that your question can be answered against the right text.
E-learning by standard
These are the GMJ Academy courses named in the criteria of this standard. Each course name opens the course page in the academy. Where a course is published in English and in Georgian, both versions are linked. Evidence of completion is a verified micro-credential in the GMJ Academy micro-credential portfolio, or a training certificate in the staff file.
| E-learning course | Who must take | Who is recommended | Criteria |
|---|---|---|---|
| Ophthalmology & Day Surgery Safety (AMB-15) GMJ Academy: English · Georgian |
Theatre team | None | 7.1, 7.2, 7.3, 7.4, 7.5, 7.6 |
| WHO Surgical Safety Checklist and team pause, for field teams (FLD-03) GMJ Academy: English · Georgian |
None | Field teams | 7.1 |
| Safe Surgery: Correct Site, Procedure, Patient (PS-04) GMJ Academy: English · Georgian |
Theatre team | None | 7.1, 7.4, 7.6 |
| Safe Anaesthesia and Sedation (PS-13) GMJ Academy: English · Georgian |
Theatre team | None | 7.2 |
| Surgical Site Infection Prevention (PS-15) GMJ Academy: English · Georgian |
Theatre team | None | 7.3 |
| Sterilization, Disinfection and Reprocessing (PS-07) GMJ Academy: English · Georgian |
None | Theatre team | 7.3 |
| Infection Prevention and Control Essentials (BAS-05) GMJ Academy: English · Georgian |
None | Theatre team | 7.3 |
| Credentialing, Competence and the Training Matrix (T-14) GMJ Academy: English · Georgian |
None | Clinical lead, Medical director | 7.4 |
| Recognising and Responding to the Deteriorating Patient (PS-12) GMJ Academy: English · Georgian |
Theatre team | None | 7.5 |
| Sharps and Clinical Waste Handling (BAS-02) GMJ Academy: English · Georgian |
Theatre team | None | 7.6 |
References and guidelines for this standard
The guidelines and references cited in the criteria above are listed here. Each link opens the full text.
- World Health Organization (2009). Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Used for: the surgical safety checklist and its three pauses (7.1). https://news.gmj.ge/guideline/guidelines-for-safe-surgery-2009-safe-surgery-saves-lives/
- World Health Organization. Anaesthesia at the district hospital, second edition. Used for: anaesthesia practice and equipment checks where resources are limited (7.2). https://news.gmj.ge/guideline/anaesthesia-at-the-district-hospital/
- World Health Organization (2018). Global guidelines for the prevention of surgical site infection, second edition. Used for: the measures that prevent surgical site infection (7.3). https://news.gmj.ge/guideline/global-guidelines-for-the-prevention-of-surgical-site-infection-second-edition/
- World Health Organization. Implementation manual to support the prevention of surgical site infections at the facility level. Used for: putting the prevention measures into practice in a facility (7.3). https://news.gmj.ge/guideline/implementation-manual-to-support-the-prevention-of-surgical-site-infections-at-the-facility-level-turning-recommendations-into-practice/
- World Health Organization (2007). WHO Nine Patient Safety Solutions. Used for: performance of the correct procedure at the correct body site (7.4). https://news.gmj.ge/guideline/who-nine-patient-safety-solutions-2007/
- Association of Anaesthetists of Great Britain and Ireland (2013). Immediate Post-anaesthesia Recovery 2013. Used for: monitoring and staffing in the recovery area (7.5). https://news.gmj.ge/guideline/immediate-post-anaesthesia-recovery-2013/
- Association of Anaesthetists and British Association of Day Surgery (2019). Guidelines for Day-Case Surgery. Used for: discharge criteria and written advice after day surgery (7.5). https://news.gmj.ge/guideline/aoa-bads-guidelines-for-day-case-surgery-2019/
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