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Policies,Clinical,UWHC Clinical,Department Specific,Surgical Services,Safety

Operating Room Blood Refrigerator Monitoring (6.07)

Operating Room Blood Refrigerator Monitoring (6.07) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Safety

6.07

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

SEPTEMBER 1992
ORIGINAL
 REVISION

MARCH 2017
PAGE 1
OF 2
POLICY #

6.07
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
OPERATING ROOM BLOOD
REFRIGERATOR MONITORING



I. PURPOSE

To ensure the safe storage of blood and blood products for utilization during surgical procedures.

II. POLICY/PRINCIPLE

The mechanism for continuous recording of the temperature in a unit storing blood products is an electronic
record. Temperature recordings monitor the internal temperature for one complete week consisting of seven
(7) days.

A member of the Operating Room staff must check the refrigerator for proper operation prior to placing
blood/blood products in the refrigerator. Temperatures, digital and graph temperature recording, must be
within the range of 1-6 θ C to assure the refrigerator is and has been functioning appropriately.

III. PROCEDURE

ALL ALARMS/TEMPERATURE VARIATIONS AND CORRECTIVE ACTIONS MUST BE
DOCUMETED AND CORRECTIVE ACTION MUST BE TAKEN IMMEDIATELY!

A. University Hospital and UW Health at The American Center
1. Operating room refrigerators are monitored continuously through an electronic system.
a. Daily, weekly, and monthly monitoring is stored in the electronic system and tracked by
facilities associates.
b. E-mail notifications are sent to facilities associates and operating room management team
when refrigerators are out of range.
c. When a variance in temperature occurs, facilities associates make an electronic notation
indicating any corrective action taken.
d. A daily physical inspection of each refrigerator will be performed by a member of the OR
staff and documented on a paper chart.
e. A member of the OR staff will login and view the electronic record daily.
B. Quarterly:
1. Each refrigerator must be monitored/checked to confirm accuracy of upper and lower limit
alarms.
2. Fill cups with cold tap water.
3. Adjust “High” cup temperature to approximately 5.5 θC (up to a degree above) with chipped ice.
4. Adjust “Low” cup temperature to approximately 1.5 θC (down to a degree below) with chipped

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

SEPTEMBER 1992
ORIGINAL
 REVISION

MARCH 2017
PAGE 2
OF 2
POLICY #

6.07
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Surgical Services
TITLE
OPERATING ROOM BLOOD
REFRIGERATOR MONITORING



ice.
5. Start with the “High” cup, immerse the sensor and wait. Alarm should be activated after a few
minutes.
6. Repeat with the “Low” cup.
7. Record the temperatures on the Refrigerator Alarm Activation Record (Form # 10.071). This
is done every four months.
8. Record the date and initials on the refrigeration chart at the temperature blip on the chart.
C. Yearly:
1. Calibration of electronic thermometers will be done by Plant Engineering yearly.
D. Alarms Do Not Activate
If the alarms do not activate within the 1-6oC range, the refrigerator must not be used until the
sensor is fixed or replaced. Follow the repair/maintenance protocol:
1. Remove any blood products and place in a safe environment (another refrigerator or obtain a
cooler from the Blood Bank).
2. Attempt to fix the problem. (e.g. check for open door, stylus off the graph, etc.) re-evaluate the
temperature after fifteen minutes.
3. If the problem cannot be readily fixed, place a sign on the refrigerator “DO NOT USE UNTIL
FURTHER NOTICE!”
4. Place a work order in for repair and notify the charge nurse immediately.



REVIEWED BY

Amira Samrah, Senior Medical Technologist 3/2017
Trisca Parrell, Surgical Services Supervisor 3/2017
Surgical Services Policy and Procedure Committee 3/2017

SIGNED BY

Anne Mork, MHCDS, MS, RN
Interim Director, Surgical Services Department