Syringe driver BME-2271 — MicroDose MD-60, Operating Theatres
18 of 18 points observed
Equipment tracer — life-support device · Ravi Shanmugam
Surveyor Tracer Final Report
Official Joint Commission International accreditation tracer summary
Syringe driver BME-2271 — MicroDose MD-60, Operating Theatres
Equipment tracer — life-support device · Operating Theatres
- Point Compliance
- 75%
- 16 checkpoints scored
- Findings Raised
- 0
- Actionable deficit citations
- Surveyor Sign-off
- Ravi Shanmugam
- Attested 2026-09-16
Chapter Compliance Telemetry
Standard adherence computed across all observed checkpoints for this trace
- MOI4 checkpoints1 gap63%
- FMS13 checkpoints2 gaps69%
- QPS2 checkpointsClean75%
- GLD3 checkpointsClean100%
- SQE1 checkpointClean100%
- MMU1 checkpointClean100%
- IPSG2 checkpointsClean100%
- PCI1 checkpointClean100%
What you have recorded
18 of 18 points- ProcurementCompliant
Clinical specification and selection
Asked two members of staff independently; both described the same process and located the evidence.
Facilities·4 of 10 records compliant·demonstrated·GLDFMS·1 evidence artifact - ProcurementPartial
Supplier and recall route
Process is understood and mostly followed, but the record is incomplete for part of the period reviewed.
Facilities·4 of 10 records compliant·demonstrated·FMSMOI·1 evidence artifact - Acceptance testingPartial
Incoming inspection
Practice was correct where observed, though staff could not locate the governing document on the unit.
Facilities·9 of 10 records compliant·described·FMS·2 evidence artifacts - Acceptance testingNon-compliant
Asset register entry
The evidence produced contradicts the written process for this unit.
Facilities·7 of 10 records compliant·demonstrated·FMSMOI·1 evidence artifact - CommissioningNot applicable
User training before first use
No patients meeting the criterion were present during the trace.
Facilities·SQE·1 evidence artifact - CommissioningCompliant
Default and limit configuration
Practice at the bedside matched the written process; the record was complete and timed.
Facilities·5 of 10 records compliant·demonstrated·MMUIPSG·1 evidence artifact - In serviceCompliant
Alarm settings and response
Asked two members of staff independently; both described the same process and located the evidence.
ICU·7 of 10 records compliant·demonstrated·FMSIPSG·1 evidence artifact - In serviceCompliant
Between-patient reprocessing
Staff demonstrated the step without prompting and produced the record on request.
ICU·9 of 10 records compliant·described·PCI·2 evidence artifacts - Preventive maintenanceCompliant
Maintenance currency
Practice at the bedside matched the written process; the record was complete and timed.
Facilities·4 of 10 records compliant·demonstrated·FMS·3 evidence artifacts - Preventive maintenanceCompliant
Programme completion rate
Asked two members of staff independently; both described the same process and located the evidence.
Facilities·10 of 10 records compliant·demonstrated·FMSQPS·1 evidence artifact - CalibrationCompliant
Calibration traceability
Staff demonstrated the step without prompting and produced the record on request.
Laboratory·6 of 10 records compliant·demonstrated·FMSSQE·2 evidence artifacts - CalibrationPartial
Out-of-tolerance handling
Practice was correct where observed, though staff could not locate the governing document on the unit.
Laboratory·4 of 10 records compliant·described·QPSFMS·1 evidence artifact - Fault and repairPartial
Fault reporting and quarantine
Two of the sample met the standard in full; the remainder were missing a timed signature.
Facilities·5 of 10 records compliant·described·FMS·2 evidence artifacts - Fault and repairNon-compliant
Post-repair verification
Neither the practice nor the record met the standard in the sample reviewed.
Facilities·9 of 10 records compliant·demonstrated·FMS·1 evidence artifact - Recall checkNot applicable
Recall traceability
No patients meeting the criterion were present during the trace.
Facilities·FMSMOI·1 evidence artifact - Recall checkCompliant
Communication to clinical areas
Asked two members of staff independently; both described the same process and located the evidence.
Facilities·4 of 10 records compliant·demonstrated·GLDMOI·1 evidence artifact - DecommissionCompliant
Disposal and data sanitisation
Staff demonstrated the step without prompting and produced the record on request.
Facilities·10 of 10 records compliant·described·MOIFMS·1 evidence artifact - DecommissionCompliant
Replacement planning
Practice at the bedside matched the written process; the record was complete and timed.
Facilities·4 of 10 records compliant·demonstrated·GLDFMS·1 evidence artifact