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Medication Refrigerator Audit Policy (1.32)

Medication Refrigerator Audit Policy (1.32) - Policies, Administrative, UWHC, Department Specific, Pharmacy, Administration

1.32

POLICY & PROCEDURE





Effective Date:

January 2004
Pharmacy Policy Manual
Chapter: Administration

Chapter:

Policy #: 1.32


 Revision 6/16

Page 1
of 3

Title: Medication Refrigerator and Freezer
(Temperature Control Systems) Audit
Policy

I. PURPOSE: To ensure medications that require refrigeration are stored in a temperature
controlled environment suitable for maintaining good stability and ensuring potency of the
product through the manufacturers stated shelf life.

II. POLICY: Temperature Control Systems (TCS) such as refrigerators and freezers for
medication storage shall be audited to assure that temperatures are maintained within an
acceptable range.
A. Medication storage refrigerators and freezers will have a Primex automated temperature
monitoring device installed and the temperatures will be monitored by the UWHC Plant
Engineering Department.
B. For areas without the ability to use an automated temperature monitoring device (such as
CHETA) the site staff will post the temperature logs on the refrigerators.
C. Some medication storage area may require both a manual record in addition to automated
monitoring such as refrigerators in the VFC program (see below).

III. FORMS (posted on UConnect – Workspaces – Pharmacy – Forms)
A. Refrigerator Log form
(used in all locations without automated monitoring )
B. VFC Refrigerator Log form
(used in East, West and University Station Pediatric Clinics only in addition to automated
monitoring)

IV. PROCEDURE:
A. Primex
1. The UWHC will utilize the Primex automated temperature monitoring, recording and
documentation system for all medication storage refrigerators and freezers.
2. Whenever the temperature has fallen outside the desired range, a member of the
UWHC Engineering Department will log into to the system, review performance of
TCS and assess the likely cause of the alert.
3. A member of the UWHC Engineering Department will physically inspect the TCS in
alert and discuss with the Area Contact (phone information provided on the alert)
when needed and discuss alert and obtain additional information on the cause of the
issue.
4. A member of the UWHC Engineering Department will take appropriate action to
resolve the issue in consultation with area contact as needed.
a. EXAMPLE ACTIONS
i. Contact steamfitter to initiate repairs if they are on duty.
ii. Adjust temperature settings.
iii. Install a backup refrigerator when appropriate after hours (when steamfitter
not available).

POLICY & PROCEDURE





Effective Date:

January 2004
Pharmacy Policy Manual
Chapter: Administration

Chapter:

Policy #: 1.32


 Revision 6/16

Page 2
of 3

Title: Medication Refrigerator and Freezer
(Temperature Control Systems) Audit
Policy

1. Backup refrigerators are available for most Clinic and Nursing Unit
Medication storage locations.
iv. Contact steamfitter on call.
5. A member of the UWHC Engineering Department will review mean kinetic
temperature (MKT) and follow up with area contact when MKT is out of range.
a. Area contact will work with a member of the UWHC Engineering Department to
determine alternative storage if needed.
b. Area contact will handle disposition of any medication that may be compromised
based upon evaluation of storage temperatures and properties of medications.
c. A member of the UWHC Engineering Department will document resolution in the
Primex System within two hours of receiving the alert.
6. If alert is not resolved within two hours, escalation through a new Primex alert to
engineering and department management will occur.

B. Manual Temperature Monitoring Systems
1. Units will have electronic monitoring devices which display temperature readings and
alarm when temperatures are not in desired range.
a. Alarm ranges are 36 – 46 θ F for refrigerators and -15 to 5 F for freezers.
b. If there are difficulties with the device, the pharmacy technician should be
notified and will replace, reset, or repair the device as needed.
2. On a daily basis, a pharmacy or site staff person will inspect refrigerators and freezers
to determine that temperatures have been within the appropriate range (36-46 θ F for
refrigerators and -15 to 5o F for freezers) and document on the appropriate
refrigerator log form (log).
a. Each day the temperatures (current, max and min) shall be read from the
monitoring device.
b. After review and documentation on the log the clear memory button must be
pressed and documentation of this action recorded on the log so that only the time
since the temperature was last checked will be stored on the monitor.
3. In the event that the refrigerator temperature is not within the accepted range, the
pharmacy technician or site staff member shall notify the pharmacy contact who will
determine medication stability and need for replacement.
4. In the event that the refrigerator requires service, the appropriate supervisor for the area
will work with the Plant Engineering Department so that the refrigerator can be
repaired. In the interim, refrigerated medications will be moved to a replacement.


POLICY & PROCEDURE





Effective Date:

January 2004
Pharmacy Policy Manual
Chapter: Administration

Chapter:

Policy #: 1.32


 Revision 6/16

Page 3
of 3

Title: Medication Refrigerator and Freezer
(Temperature Control Systems) Audit
Policy

5. Completed copies of the log will be sent to pharmacy office F6/133 and kept for 3
years.


Approved By:_________________________
Director of Pharmacy Services

Date:_______________

Web Posted - Policy updates need to be placed on pharmacy web site