HOSPITAL NAME Department: TITLE/DESCRIPTION REFRIGERATED MEDICINE EFFECTIVE REVIEW DUE DATE INSTITUTIONAL POLICY AND PROCEDURE (IPP) Manual: Section: POLICY NUMBER REPLACES NUMBER APPROVED BY NO. OF PAGES APPLIES TO PURPOSE The purpose of this policy is to provide a monitoring process for all refrigerator and freezers located within the department. DEFINITION Refrigerate : 36 Degrees – 46 degrees Fahrenheit (2 degrees – 8 degrees Celsius) Freezer: Below 32 degrees Fahrenheit (0 degree Celsius) – consult a manufacturers literature per products as some products that require lower freezer temperatures than others. RESPONSIBILITY This policy applies to all Pharmacy & Nursing Personnel. CROSS REFERENCES POLICY 1. All refrigerators and freezers located within the department will be routinely monitored to assure that the correct temperature range is maintained with respect to the items being stored in each respective refrigerator or freezer. A hard copy documentation of this monitoring process will be maintained for one year. 2. Vaccines can be classified according to their heat or photosensitivity. 2.1. Moderately or highly – heat sensitive vaccines BCG, measles, HIB, MMR or any of its components must be kept at +4 to +8°C. 2.2. Relatively heat resistant vaccines such as DPT, DT, TT, HBV and Gamanaglobulins. They can be destroyed by freezing. 2.3. Photosensitive vaccines such as BCG and measles (packed in dark bottles). 3. Medication Refrigerators: 3.1. Medication refrigerators will not be used for storing foods or specimens. Refrigerators labeled as "Drug ONLY". 3.2. Each unit must monitor and record the temperature twice daily and notify Maintenance Department if temperature falls outside the range of 2 – 8°C and take necessary actions to protect drugs till the problem is fixed. JCI Standards CBAHI Page 1 of 2 3.3. Each unit is responsible to maintain a clean refrigerator. 3.4. Review medications for out-dates, returning those to pharmacy a minimum of thirty (30) days prior to expiration date. PROCEDURE 1. Vaccines refrigerator must be arranged as follows: A. Don’t keep more than one month stock in the refrigerator. B. Keep the refrigerator temperature between 2 degrees to 8 degrees Celsius. C. No vaccines in the door of the refrigerator. D. Nothing other than vaccines allowed being inside the refrigerator. E. Keep space between the packs of vaccines to allow air around. F. Consider the manufacturer's instruction about vaccine storage. G. Polio vaccine freezer temperature should be between -10 to -20 degree Celsius H. Medicine should be arranged in a manner clearly visible of their labels. I. Pharmacist should check for the expiration date of the medicine every two weeks. J. The First In First Out (FIFO) must be applied. Medicine with lesser expiration date should be placed in front before medicine with long term expiration date. 2. Refrigerator temperature should be checked and monitor twice a day and record the temperature twice daily; notify Maintenance Department if temperature falls outside the range or 2 - 8 degree Celsius and take necessary actions to protect drugs till the problem is fixed. 3. There should be list attached inside the refrigerator for all medicine. FORMS EQUIPMENT REFERENCES APPROVAL: Name Signature Date Prepared by Reviewed by Approved By Approved By Latest Revision Approved By JCI Standards CBAHI Page 2 of 2