Fridge Temperature Monitoring - the Royal Cornwall Hospitals Trust ...

STANDARD OPERATING PROCEDURES:PROCEDURE FOR FRIDGE TEMPERATURE MONITORING.MAINTAINING COLD SUPPLY CHAINTitle: Fridge temperature monitoringOn Behalf of: Dental Service Clinical StaffPrepared by: Janice South, Community Pharmaceutical AdviserApproved by:Helen NewsonDirector of Nursing and Professional PracticeDate approved:Approved by:Clinical Director Dental ServicesNeil McDonaldDate approved:Fridge Temperature Monitoring:Readings must be made daily¹ using a maximum – minimum thermometer, inaccordance with manufacturer’s instructions.On the Refrigerator Temperature Record Chart, record daily the date andtime of the temperature reading, the current temperature, maximum andminimum temperatures and sign in the ‘Checked by’ column.The reset button must be pressed after recording the temperature each day,in order to obtain a new baseline. Record the reset by placing a tick in thelast column of the Refrigerator Temperature Record Chart.The temperature of the fridge must be kept between the range +2ºC and+8ºC. Record on the Record Chart any actions taken to ensure temperaturerange is maintained (eg temperature adjustments on fridge) or any knownreasons for temperature fluctuation (eg stocking up the fridge may causetemporary increase in temperature).If fridge temperature is outside the stated range (2º-8ºC) seek advice fromyour supplying pharmacy on the viability of any medication or vaccine, anddocument advice given. NB Please ensure you have details of fridgetemperatures, manufacturer and batch no. available.If you are unable to check with pharmacy, or manufacturer, that medicines orvaccines stored outside the range +2º to +8º C can be used safely, and/oruntil the fridge is fully working and maintaining the temperature range,quarantine the stock (put in a container or bag, marked clearlyQUARANTINED STOCK – DO NOT USE). Place in a fridge maintainedwithin temperature range until you are able to confirm whether the stock canbe safely used, or needs to be disposed of. Take care not to jeopardiseexisting stock by overfilling the fridge, see Good Practice Guidelines.File and retain completed Refrigerator Temperature Record Charts for aperiod of 2 years.REF: CG-DEN-R03 Issue: 1 Review Date: 16/10/15

¹For any units not staffed 7 days a week, monitor every working dayFridge maintenance: The refrigerator must be cleaned, defrosted (if applicable according tomanufacturer’s instructions) and the stock date-checked monthly, with thedates recorded on the Refrigerator Temperature Record Chart.Electrical and calibration tests must be completed on all fridges annually.Good Practice Guidelines:Each ward/unit handling vaccines should have one designated individual,and at least one deputy, responsible for the receipt and storage of vaccines.Vaccines and medication should be stored in a refrigerator immediately onreceipt. The fridge should only be used to store vaccines and/or medicines.NO FOOD, DRINK OR BODY FLUID SAMPLES should be stored in thefridge, to limit the chance of changes in temperature and to limit and minimisethe risk of contamination.Do not store vaccines or medication in the door, bottom drawer or next tofreezer plate of the fridge, as these areas are more vulnerable to temperaturevariations outside recommended range.Do not overfill the fridge. Air within the fridge needs to circulate to maintainconstant temperature throughout fridge.The fridge cabinet should have sufficient space around it for air to circulate,and not be obstructed.Fridges should be lockable or within a lockable roomSwitch-less sockets or cautionary labels on plugs and sockets can helpprevent accidental interruption of power supply.Where readings below 2ºC and above 8ºC are regularly recorded ensurethermometer is being used according to instructions, and fridge is workingcorrectly. It is unlikely the temperatures recorded will be the same every day,due to variations in temperature when fridge door is opened and closed, andchanges in ambient room temperature.Faulty Fridges: Faulty fridges should be reported via CHESS Estates Intranet reportingprocedure (Intranet > Quicklinks > CHESS Estate Helpdesk).For out of hour’s emergencies, contact on-call manager.Further information on cold storage chain:1. Vaccine storage in ‘Immunisation Against Infectious Disease’ Chapter 3 (TheGreen Book)http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079917REF: CG-DEN-R03 Issue: 1 Review Date: 16/10/15

2. NPSA Alert : NPSA/2010/RRR008http://www.nrls.npsa.nhs.uk/resources/?entryid45=66111&p=23. Please contact local Pharmacy Department for access to UKMi fridge database(password is required to access) http://www.ukmi.nhs.uk/applications/fridge4. Summaries of Product Characteristics (SPCs) gives information on storagerequirements for individual medications.http://www.medicines.org.uk/EMC/5. Medicines information services provide information on vaccine stability and providedetails on local services within your area. Contact numbers can be found on insidecover of BNF.Pharmacy contact details:Royal Cornwall Hospitals Trust (Medicines Information)01872 252587North Devon (via switchboard) 01271 322577Callington Lloyds Pharmacy 01579 383106If unable to contact pharmacy, affected stock should be quarantined and advicesought from pharmacy beforeusing affected stock.REF: CG-DEN-R03 Issue: 1 Review Date: 16/10/15