6.2.1Safety Standard
Policies and proceduresAntimicrobial Stewardship (AMS) Programme
A multidisciplinary Antimicrobial Stewardship team enforces restricted antimicrobial authorization, prescription guidelines and antibiotic utilization monitoring.
Compliance Criteria
- 1Multidisciplinary AMS committee comprising Infectious Disease Specialist, Pharmacist and Microbiologist
- 2Hospital antimicrobial formulary with predefined restricted antimicrobials list
- 3Prospective audit and feedback mechanism with 72-hour antibiotic timeout
- 4Annual hospital cumulative antibiogram published and disseminated to prescribers
Hospital Self-Rating
Rated by Dr. Tan Mei Ling on 22 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Antimicrobial stewardship programme monitors restricted antibiotic prescriptions with 72-hour review and annual antibiogram distribution."
thin
Evidence documents establish procedural intent but lack documented verification records for the current audit period.
Unverified criteria:
- Prospective audit and feedback mechanism with 72-hour antibiotic timeout
- Annual hospital cumulative antibiogram published and disseminated to prescribers
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (1)
PolicyAcceptedScore: 94/100
Antimicrobial Stewardship (AMS) Formulary & Antibiogram Guide
50 pages · ENValid: 2025-01-01 to 2026-12-31
TL
Person-in-ChargeInfection Control Officer & Consultant Microbiologist
Head of DepartmentHead of Pharmacy Services
SN
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)