Cold Chain Audit in compliance to NSQHS Std 4.10.3 Yang Liu Stephen Lim Pam Allsop Pharmacy...
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Transcript of Cold Chain Audit in compliance to NSQHS Std 4.10.3 Yang Liu Stephen Lim Pam Allsop Pharmacy...
Cold Chain Audit in compliance to NSQHS Std 4.10.3
Yang Liu
Stephen Lim
Pam Allsop
Pharmacy Department
Objective
To assess compliance to the Department of Health Vaccine Cold Chain Guideline (OD0355/11)
To promote medication safety at AHS by ensuring correct storage of temperature- sensitive products
Method
Audited all refrigerators at AHS and the corresponding community centres
Compliance to the Department of Health Vaccine Cold Chain Guideline (OD0355/11) was assessed
Survey period: 17th – 28th of June 2013
Std 4.10.3
Temperature- sensitive medicines are stored appropriately and in accordance with manufacturer’s recommendation
Use refrigerators specifically for cold chain products only and ensure they are fitted with temperature recording devices
What is Cold Chain?
A system of transporting and storing vaccines within the recommended safe temperature range of +2ºC to +8ºC
ManufacturedTransported to
distribution centres Administered
Shared responsibility
Strive for 5!
Cold Chain Breach (CCB)
Occurs when the temperature falls outside of the recommended temperature range of +2°C to +8°C at any point during the cold chain process
Due to:• Refrigeration failure• Power outage• Overheating during transportation• Freezing
Leading to a loss of efficacy to the vaccine
Vaccine storage management
Delicate biological substances Ensure individuals receive an effective health
product Expensive and may be in short supply Destroyed or become less effective when
exposed to:• Freezing (≤ 0°C)• Heat• Direct sunlight or fluorescent light
Most vaccines can be regarded as damaged at 0ºC
Results
Finding Percentage compliance Type of fridge Purpose built: 75% Bar: 25%
Vaccine storage only 0%
Temperature monitored daily 57.9%
Temperature chart used for daily monitoring 68.4%
Person responsible for daily temperature monitoring
Nurses: 80% Other: 20%
Approved temperature recording device installed 84.2%
Fridge is plugged into essential power 84.2%
Signage affixed to the fridge door indicating its contents
10.5%
Fridge maintained according to manufacturer's instructions
63.2%
Fridge is centrally monitored 68.4%
Fridge cleaned routinely 31.6%
Aware of cold chain policy in this hospital 68.4%
Discussion
Vaccines and temperature- sensitive medicines are stored in the same refrigerator throughout the hospital
Installing a purpose built refrigerator is not yet at 100% compliance on all wards
Fridges must be consistently monitored daily and temperatures recorded at the same time each day
No designated person is responsible for educating or implementing policies
Discussion
Refrigerators which contained vaccines did have an essential power supply and monitored centrally at AHS
Updated imprest list of refrigerator contents were placed on the door
Do not store food and other goods in the fridge Equipment maintenance should be conducted
annually and include:• Changing thermometer batteries
• Checking the accuracy of the thermometer
• Defrosting and cleaning the fridge
Discussion
Wastage due to power failure Cost of new refrigerator ranges from
$1595 to $3195
Ward AMU contents
worth $323.69
Ward: ED contents
worth $5066.93
Conclusions
The Department of Health Vaccine Cold Chain Guideline (OD0355/11) was not adhered to at AHS
An individual needs to be appointed in each area to oversee cold chain management
Ongoing education to all staff is vital Re- audits will be performed regularly to
ensure implementation of recommendations