Back to Standards/Criterion 09F.4.3.25
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorNot applicable
Mr Ganesh PillaiRecorded finding during tracer inspection

Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.

09F.4.3.25New in the 7th Edition
Human resource development and management

Anaesthetic Equipment Safety Protocol 4.3

The Anaesthetic Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for anaesthetic equipment safety.

Compliance Criteria

  • 1Approved standard operating procedure for anaesthetic equipment safety reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day anaesthetic equipment safety compliance
  • 3Regular documentation audits and evidence of corrective action implementation
  • 4Staff training records and competency assessments maintained in the department

Hospital Self-Rating

Rated by Dr. Lim Chee Keong on 25 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"The department has established comprehensive operational policies for anaesthetic equipment safety. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."

Evidence Documents (0)

A criterion with no document reads as unevidenced to the survey team.

Attach relevant hospital policies, registers, audit reports, or training records.

LK
Person-in-ChargeHead of Anaesthesia & Operating Theatres
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 15 Apr 2026

Departmental scope verification confirms that anaesthetic equipment safety is not applicable to the operational services provided by Anaesthetic Services at this facility.

None specified.

None specified.