Surveyor Consensus & Allocation Dispute
Team leader to resolveLead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Pn Zaiton AbdullahRecorded finding during tracer inspectionAwaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.
5.2.1Core StandardSafety Standard
Policies and proceduresSafe Medication Administration by Nurses
Nursing personnel adhere strictly to the 7 Rights of medication administration, verifying patient identity, medication, dose, route and time.
Compliance Criteria
- 1Strict enforcement of the 7 Rights of medication administration
- 2Two-nurse independent double-check protocol for high-alert medications (HAM)
- 3Use of dual patient identifiers (Name & MRN) prior to medication administration
- 4Prompt documentation of administered medications and omission reasons
Hospital Self-Rating
Rated by Matron Norliah binti Hashim on 15 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"The 7 Rights of medication administration and independent double-check for high-alert medications are strictly enforced across all ward units."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Use of dual patient identifiers (Name & MRN) prior to medication administration
- Prompt documentation of administered medications and omission reasons
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
PolicyAcceptedScore: 94/100
Safe Medication Administration & Independent Double-Check Protocol
30 pages · ENValid: 2025-03-01 to 2028-03-01
NH
Person-in-ChargeDirector of Nursing
Head of DepartmentHead of Pharmacy Services
SN
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)