AccrediSense
Back to Standards/Criterion 16.3.1
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Pn Zaiton AbdullahRecorded 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.

16.3.1Safety Standard
Special requirements

Instrument Traceability and Tracking to Patient

A tracking system records surgical instrument sets from decontamination through sterilisation, theatre delivery and patient usage.

Compliance Criteria

  • 1Unique barcode or tracking tag attached to every instrument set
  • 2Documentation of instrument set batch number in patient theatre nursing record
  • 3Traceability protocol enabling rapid recall of all packs from compromised loads
  • 4Periodic audit of instrument traceability compliance in surgical cases

Hospital Self-Rating

Rated by Pn. Zainab binti Sulaiman on 19 Jan 2026

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

"Instrument tracking barcodes record pack sterilization lots and tie surgical tray usage to specific patient operative records."

AccrediSense Intelligence
unsupported

No evidence documents attached to substantiate this self-assessment claim.

Unverified criteria:
  • Unique barcode or tracking tag attached to every instrument set
  • Documentation of instrument set batch number in patient theatre nursing record
  • Traceability protocol enabling rapid recall of all packs from compromised loads
  • Periodic audit of instrument traceability compliance in surgical cases
Derived from AccrediSense Evidence Engine · 0 documents attached against 4 compliance criteriaGovernance disclosure (1.4.1.4)

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.

ZS
Person-in-ChargeCSSD Supervisor
Head of DepartmentHead of Anaesthesia & Operating Theatres
LK
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Instrument set barcode tracking links sterilisation batch loads directly to patient operative records, enabling rapid batch tracing.

Extend barcode scanning to individual specialty supplementary instruments.

Sustain comprehensive instrument traceability.