18.4.2.24
Policies and proceduresHigh-Alert Drug Storage Protocol 4.2
The Pharmacy Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for high-alert drug storage.
Compliance Criteria
- 1Approved standard operating procedure for high-alert drug storage reviewed within the last 3 years
- 2Designated qualified personnel assigned to monitor day-to-day high-alert drug storage 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. Suresh Nair on 24 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The department has established comprehensive operational policies for high-alert drug storage. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Approved standard operating procedure for high-alert drug storage reviewed within the last 3 years
- Designated qualified personnel assigned to monitor day-to-day high-alert drug storage compliance
- Regular documentation audits and evidence of corrective action implementation
- Staff training records and competency assessments maintained in the department
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.
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)