(Maintaining the Cold Chain) For - Halton and St Helens PCT

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Opening of the refrigerator door should be kept to a minimum.All vaccines are Prescription Only Medicines (POMs) and must be stored under lockedconditions. Refrigerators must either be lockable or within a room that is locked when notoccupied by a member of staff. Vaccines should never be left unattended at outlying clinics.Refrigerators should not be situated near a radiator, or any heat source that could affecttheir working, and should be appropriately ventilated.3.1 DefrostingIce should not be allowed to build up within the refrigerator as this reduces effectiveness.Records should be kept of regular servicing, defrosting and cleaning. Ideally, refrigeratorsshould be self-defrosting. If the refrigerator is not self defrosting, it should be defrostedmonthly by hand by the designated person or their deputy.An approved, validated cool box with appropriate temperature monitoring, or alternativerefrigerator should be used to store vaccines during defrosting of the main refrigerator. Afterdefrosting, vaccines should only be replaced once the refrigerator has returned to thecorrect temperature.3.2 Refrigerator MaintenanceRefrigerator inspections will be carried out yearly by the PCT Maintenance Service.Calibration of thermometers will be included (contracted services will be included in theprogramme).If the vaccine refrigerator breaks down the named individual or their nominated deputy mustbe informed, they in turn must contact the PCT Immunisation Co-ordinator.Ideally, an alternative refrigerator must be used immediately. If an alternative fridge isunavailable then a validated cool box will suffice. Practices should consider agreeingcontingency plans with neighbouring health care premises.Vaccine refrigerators must be clean and dry at all times.There must be constant electrical supply to the vaccine refrigerators. Ensure the plugs areclearly marked Vaccine Refrigerators so they are not disconnected, or use a switchlesssocket.If the refrigerator is not working properly (this may be evidenced by a fluctuatingtemperature) contact the Maintenance Department.FOR ANY INCIDENT RELATING TO REFRIGERATOR TEMPERATURE, AN INCIDENTFORM (IR1) MUST BE COMPLETED.Page 8 of 23
If incident occurs in general practice, please inform the PCT Immunisation Coordinator,(01744 627572) and follow PCT procedures for Incident Reporting.4. Refrigerator ThermometersThe temperature within the vaccine refrigerator must be continually monitored with amaximum-minimum thermometer. This will identify when the temperature may have beenoutside the recommended range. Digital thermometers are the most reliable. Moresophisticated temperature recording devices are now available, including alarmed digitalmaximum-minimum thermometers. When placing thermometers / probes in the fridge,resetting and replacing them, the manufacturer’s guidance should be followed.The current, minimum and maximum fridge temperatures should be recorded at 9am and4pm each day unless stated otherwise by the manufacturer. All readings should be recordedon the PCT refrigerator temperature monitoring sheet (Appendix 1). If all temperatures arewithin 2 0 C to 8 0 C, record this on the PCT refrigerator temperature record chart and reset thethermometer. Checking the temperature at the beginning of each day enables theidentification of any problems before the vaccine is given. Checking the temperature twicedaily will give a better indication of any problems relating to temperature fluctuations orproblems in the refrigerators function over the course of the day. However, the temperatureneeds to be viewed and considered every time the refrigerator is opened. (Ref:National vaccine storage guidelines, Department of Health and ageing, AustralianGovernment)If any of the readings are below 2 0 C or above 8 0 C the flow chart for monitoring thetemperature of medicine refrigerators should be followed (Appendix 2)All professionals are responsible for ensuring that vaccines are stored correctly.4.1 Temperature DeviationIf the minimum temperature reads below +2°C, or the maximum temperature reads above+8°C, the first contact must be Hospital Medicine Information Department and follow theadvice given. If required the Medicine Information Team will contact the company thatsupply the vaccines and provide further advice if required.If the deviation from the temperature range is related to opening the door, note on thelog the reason for the temporary temperature increase, as caused for example by avaccine delivery or stock take. Recheck the temperature range in 30 minutes. If thetemperature is in range then no further action is required, if the temperature is stillout of range contact follow the flow chart – Monitoring the Temperature of MedicineRefrigerators (Appendix 2) and contact the Estates department if necessary.Page 9 of 23
Page 2 and 3: CONTRIBUTION LISTKey individuals in
Page 5 and 6: 6. DefinitionsVaccine - noun a subs
Page 7: Process Document for The Safe Distr
Page 12 and 13: Vaccines can be returned to the ref
Page 14 and 15: REFRIGERATOR TEMPERATURE MONITORING
Page 16 and 17: Appendix 3Refrigerator DiagramVacci
Page 19 and 20: e. R & L Slaughter Ltd.,Units 11 &
Page 21 and 22: APPENDIX 5EQUALITY IMPACT ASSESSMEN
Page 23: Medicines Management carry out Safe

(Maintaining the Cold Chain) For - Halton and St Helens PCT

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