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Back to Standards/Criterion 10.4.2.24
10.4.2.24New in the 7th Edition
Safety and performance improvement activities

Sterility Assurance Protocol 4.2

The Operating Suite Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for sterility assurance.

Compliance Criteria

  • 1Approved standard operating procedure for sterility assurance reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day sterility assurance 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 24 Jan 2026

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

"The department has established comprehensive operational policies for sterility assurance. 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: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Review of sterility assurance monitoring files in Operating Suite Services identified overdue quarterly audits and incomplete corrective action verification.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for sterility assurance.

Implement monthly documentation audits and review adherence rates during departmental quality meetings.