18.2.5Core StandardSafety Standard
Policies and proceduresMedication Reconciliation on Inpatient Admission and Transfer
A multidisciplinary medication reconciliation process verifies patient home medications and inpatient transfer prescriptions within 24 hours of admission.
Compliance Criteria
- 1Standardized medication reconciliation form integrated into clinical admission workflow
- 2Clinical pharmacist or medical officer reconciliation completed within 24 hours of admission
- 3Clarification and documentation of medication discrepancies with prescribing doctor
- 4Monthly audit of inpatient medication reconciliation completion compliance
Hospital Self-Rating
Rated by Dr. Suresh Nair on 20 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Inpatient medication reconciliation is conducted within 24 hours of admission following the comprehensive closure of SIQ-2025-024. Audits confirm 93.5% reconciliation rate."
supported
Attached documentation, registers and clinical audit trails fully substantiate all compliance criteria.
Derived from AccrediSense Evidence Engine · 2 verified documents covering all 4 compliance criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (2)
PolicyAcceptedScore: 94/100
Safe Medication Administration & Independent Double-Check Protocol
30 pages · ENValid: 2025-03-01 to 2028-03-01
PolicyAcceptedScore: 92/100
Structured SBAR Clinical Handover Protocol & Ward Observation Audits
20 pages · ENValid: 2025-04-01 to 2028-04-01
Linked Performance Indicators (1)
PI-05-001Medication Safety
Adult Inpatient Medication Reconciliation Completion Rate Within 24 Hours
18 readings recorded (Target: >= 90%)
SN
Person-in-ChargeHead of Pharmacy Services
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)