GPC Refrigerator/ freezer, medication, patient nourishment
GPC Refrigerator/ freezer, medication, patient nourishment
GPC Refrigerator/ freezer, medication, patient nourishment
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Title: <strong>GPC</strong>- <strong>Refrigerator</strong>/ <strong>freezer</strong>, <strong>medication</strong>, <strong>patient</strong><br />
<strong>nourishment</strong>, laboratory specimens, temperatures and<br />
cleaning<br />
DESCRIPTION/OVERVIEW<br />
The purpose of monitoring refrigerator/<strong>freezer</strong> temperatures is to ensure proper<br />
refrigeration/freezing of <strong>medication</strong>, specimens, and <strong>patient</strong> <strong>nourishment</strong>s.<br />
REFERENCES<br />
New Mexico State Board of Pharmacy<br />
New Mexico Department of Health (DOH)<br />
New Mexico Vaccines for Children (VFC)<br />
AREAS OF RESPONSIBILITY<br />
Executive Director Pharmacy<br />
Executive Director Dietary<br />
Executive Director Laboratory<br />
Applies To: All HSC Hospitals andCRTC<br />
Component(s): <strong>GPC</strong><br />
Responsible Department: Pharmacy<br />
Procedure<br />
Patient Age Group: (X) N/A ( ) All Ages ( ) Newborns ( ) Pediatric ( ) Adult<br />
PROCEDURE<br />
1. All refrigerators/<strong>freezer</strong>s must be labeled with what they contain –<br />
1.1. Medication Only<br />
1.2. Laboratory Specimens Only<br />
1.3. Patient Food/Drinks Only<br />
2. All refrigerators/<strong>freezer</strong>s must be labeled with their Maintenance ID# and contact<br />
phone numbers for repair issues.<br />
3. Rooms that contain <strong>medication</strong> refrigerators/<strong>freezer</strong>s must have a separate<br />
thermometer to monitor and record ambient temperature daily.<br />
4. All <strong>medication</strong>s that require freezing must be stored in a <strong>freezer</strong> that has a separate<br />
compartment (two door style); dorm style units are not acceptable. All <strong>freezer</strong>s must<br />
NOT have more than ¼ inch of ice buildup.<br />
5. Units must use log attached to this procedure for each refrigerator and/or <strong>freezer</strong><br />
located on the unit.<br />
6. Units that have VFC or DOH <strong>medication</strong> in stock: Each month must down load and<br />
use the NM Department of Health’s current Temperature log. The NM DOH requires<br />
that only their form be used. It can be obtained from:<br />
http://www.health.state.nm.us/immunize/Forms/D1Templog.pdf<br />
*Units utilizing the DOH log must also record daily High/Low temperatures on the<br />
DOH log in order to comply with this procedure.<br />
7. Units utilizing the DOH temperature log must also use the separate maintenance log<br />
attached to this procedure.<br />
_________________________________________________________________________________________________________________<br />
Title: <strong>GPC</strong> <strong>Refrigerator</strong>/ <strong>freezer</strong>, <strong>medication</strong>, <strong>patient</strong> <strong>nourishment</strong>, laboratory specimens, temperatures and cleaning<br />
Owner: Pharmacy<br />
Effective Date: 3/21/07<br />
Document ID#: 2034<br />
Page 1 of 3
8. <strong>Refrigerator</strong>/<strong>freezer</strong> for vaccines must follow the State of New Mexico regulations,<br />
unless otherwise specified by manufacturer.<br />
9. Acceptable temperature ranges:<br />
CELSIUS<br />
FAHRENHEIT<br />
<strong>Refrigerator</strong> Freezer <strong>Refrigerator</strong> Freezer<br />
Patient<br />
Food/Drink 1°C to 4°C -18°C to -23°C 34°F to 40°F 0°F to -10°F<br />
Laboratory<br />
Specimens 2°C to 8°C -26°C to - 32°C 35°F to 46°F -15°F to -26°F<br />
Medication 2°C to 8°C -10°C to - 20°C 36°F to 46°F 14°F to -4°F<br />
10. All refrigerators and <strong>freezer</strong>s will be equipped with a digital thermometer that<br />
indicates refrigerator/<strong>freezer</strong> High/Low.<br />
11. Digital thermometer alarms must be kept on auditory alarm setting.<br />
12. All units will record digital thermometer High/Low temperatures once daily, and then<br />
clear results.<br />
13. Units not operating on a 24-hour basis must clear digital thermometer the day before<br />
a weekend/holiday and record the High/Low temperatures on the log the day the unit<br />
reopens, and then clear results.<br />
14. All refrigerators will be cleaned at least monthly and documented on the log.<br />
15. Digital thermometer batteries must be changed every three months, or when<br />
thermometer indicates low battery. Battery checks are recorded monthly. See<br />
manufacturer recommendations for indications of when batteries are low.<br />
(i.e. flashing C or F).<br />
16. Digital thermometers come pre-calibrated; manufacturer packing will indicate next<br />
calibration due date<br />
19. Temperatures outside of range require documentation of action taken for variances.<br />
The refrigerator/<strong>freezer</strong> unit temperature should be monitored and adjusted every 30<br />
minutes until a stable regulation in temperature control has been achieved.<br />
20. Temperature trends may indicate a mechanical/electrical problem developing,<br />
therefore trend evaluations are important to report. If the temperature<br />
increase/decrease each day for four days, call Maintenance.<br />
21. Logs are to be kept by the Unit Director for three years.<br />
DEFINITIONS<br />
None<br />
SUMMARY OF CHANGES<br />
Added digital thermometers, recording daily Hi/Low, new log for non-VFC, new maintenance<br />
log. Replaces policy: <strong>Refrigerator</strong> Temperatures - Cleaning<br />
KEY WORDS<br />
<strong>Refrigerator</strong>, <strong>freezer</strong>, dietary, laboratory, pharmacy, log, records, maintenance logs, <strong>medication</strong>s,<br />
storing, cleaning, battery, and thermometers.<br />
_________________________________________________________________________________________________________________<br />
Title: <strong>GPC</strong> <strong>Refrigerator</strong>/ <strong>freezer</strong>, <strong>medication</strong>, <strong>patient</strong> <strong>nourishment</strong>, laboratory specimens, temperatures and cleaning<br />
Owner: Pharmacy<br />
Effective Date: 3/21/07<br />
Document ID#: 2034<br />
Page 2 of 3
RESOURCES/TRAINING<br />
Resource/Dept<br />
Cynthia Lujan Pharmacy<br />
Gretchen Brummer Laboratory<br />
Andy Walder Dietary<br />
NM Department of Health’s Vaccine For<br />
Children<br />
Internet/Link<br />
http://www.health.state.nm.us/immunize/Forms/D1Templog.pdf<br />
DOH Santa Fe office (505) 827-2415<br />
DOCUMENT APPROVAL & TRACKING<br />
Item Contact Date Approval<br />
Owner Louis Achuism, Executive Director, Pharmaceutical Services Y<br />
Consultant(s)<br />
Cynthia Lujan, Consultant Pharmacist, Ambulatory<br />
Camille Singaraju, Quality Consultant<br />
Antia Sanchez, RN, BSN, Unit Director, Southeast Heights Clinic<br />
Committee(s) [Committee Name(s)] [Y or N/A]<br />
Nursing Officer Judy L. Spinella, RN, MSN, MBA, CHE, Chief Nursing Officer Y<br />
Medical Director/Officer [Name, Department (or Chief Medical Officer)] [Y or N/A]<br />
Human Resources [Name], HR Administrator, [UNMH or UNM] [Y or N/A]<br />
Finance [Name, Title], [UNMH or HSC] [Y or N/A]<br />
Legal [Name, Title], [UNMH or HSC] [Y or N/A]<br />
Official Approver Amy Boule, Administrator, Professional and Support Services Y<br />
Official Signature<br />
2 nd Approver (Optional)<br />
Signature<br />
Effective Date<br />
Origination Date<br />
Issue Date<br />
Clinical Operations Policy Coordinator<br />
[Day/Mo/Year]<br />
[Day/Mo/Year]<br />
[Day/Mo/Year]<br />
[Month/Year]<br />
ATTACHMENTS<br />
A. Temperature Log – Food & Drink – Celsius<br />
https://hospitals.health.unm.edu/intranet/Forms/ClinicalForms/FFTL/PtFoodDrink_Celsius.doc<br />
B. Temperature Log – Food & Drink – Fahrenheit<br />
https://hospitals.health.unm.edu/intranet/Forms/ClinicalForms/FFTL/PrFoodDrink_Fahrenheit.doc<br />
C. Temperature Log – Laboratory – Celsius<br />
https://hospitals.health.unm.edu/intranet/Forms/ClinicalForms/FFTL/Laboratory_Celsius.doc<br />
D. Temperature Log – Laboratory – Fahrenheit<br />
https://hospitals.health.unm.edu/intranet/Forms/ClinicalForms/FFTL/Laboratory_Fahrenheit.doc<br />
E. Temperature Log – Medication – Celsius<br />
https://hospitals.health.unm.edu/intranet/Forms/ClinicalForms/FFTL/Medication_Celsius.doc<br />
F. Temperature Log – Medication – Fahrenheit<br />
https://hospitals.health.unm.edu/intranet/Forms/ClinicalForms/FFTL/Medication_Fahrenheit.doc<br />
G. New Mexico DOH Temperature Log<br />
http://www.health.state.nm.us/immunize/Forms/D1Templog.pdf<br />
H. <strong>Refrigerator</strong> & Freezer Maintenance Log<br />
https://hospitals.health.unm.edu/intranet/Forms/ClinicalForms/FFTL/MaintenanceLog.doc<br />
_________________________________________________________________________________________________________________<br />
Title: <strong>GPC</strong> <strong>Refrigerator</strong>/ <strong>freezer</strong>, <strong>medication</strong>, <strong>patient</strong> <strong>nourishment</strong>, laboratory specimens, temperatures and cleaning<br />
Owner: Pharmacy<br />
Effective Date: 3/21/07<br />
Document ID#: 2034<br />
Page 3 of 3
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