Back to Standards/Criterion 25.3.1.19
25.3.1.19Core Standard
Organisation and management

Cold Chain Transport Protocol 3.1

The Blood Transfusion Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for cold chain transport.

Compliance Criteria

  • 1Approved standard operating procedure for cold chain transport reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day cold chain transport 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 Pn. Salmiah Zakaria on 19 Jan 2026

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

"The department has established comprehensive operational policies for cold chain transport. 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.

SZ
Person-in-ChargeManager, Diagnostic Laboratory Services
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 15 Apr 2026

Staff interviews during tracer challenge indicated uneven adherence to cold chain transport protocols during weekend coverage, despite available departmental guidelines.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for cold chain transport.

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