18.1.1Core StandardSafety Standard
Facilities and equipmentPharmacy Licensing and Medication Storage
Pharmacy premises comply with Poisons Act 1952, maintaining secure storage, temperature monitoring and restricted dangerous drugs safes.
Compliance Criteria
- 1Registered Pharmacist on duty with valid Annual Retention Certificate (ARC)
- 2Double-locked dangerous drugs (DDA) safe with strict register balance audits
- 3Calibrated continuous pharmaceutical refrigerator temperature monitoring (2–8°C)
- 4Segregated storage for cytotoxic, flammable and sound-alike look-alike (LASA) drugs
Hospital Self-Rating
Rated by Dr. Suresh Nair on 16 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Pharmacy storage complies with Poisons Act. Dangerous drugs safes are double-locked with daily inventory counts and 2–8°C fridge logs."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Registered Pharmacist on duty with valid Annual Retention Certificate (ARC)
- Double-locked dangerous drugs (DDA) safe with strict register balance audits
- Calibrated continuous pharmaceutical refrigerator temperature monitoring (2–8°C)
- Segregated storage for cytotoxic, flammable and sound-alike look-alike (LASA) drugs
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.
Linked Performance Indicators (1)
PI-18-001Pharmacy & Medication
Medication Administration Error Rate with Harm per 10,000 Occupied Bed Days
18 readings recorded (Target: <= 0.5per 10,000 bed days)
SN
Person-in-ChargeHead of Pharmacy Services
Head of DepartmentChief Executive Officer
RI
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)