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1
MMP1: Temperature Monitoring in Clinic Rooms
Procedure Description
This procedure describes the process to be followed for temperature monitoring in all clinical
areas where medicines are stored.
Which policy does the procedure link to
Trust Policy
reference MM01: Medicines Management Policy
Version Number Version 6
Date of issue/
implementation July 2019
Written by Orla Macdonald (Clinical Lead Pharmacist for Research &
Development)
Amended by Joanne Galloway (Clinical Trials Pharmacist)
Richard Hunponu-Wusu (Clinical Lead Pharmacist)
Approved by
Name: Michael Marven
Position: Deputy Chair, DTG
Date: 31st July 2019
Signature:
On behalf of Drug & Therapeutics Group
Name: Michael Marven
Position: Chief Pharmacist
Date: 31st July 2019
Signature:
Chief Pharmacist
Date of review July 2021
2
Responsibilities
Ward/Unit Managers, Nurses and Pharmacy Staff (see section 4 of the procedure for further
details.
Procedure 1. Introduction
Medicines should be stored under conditions which ensure that their quality is not adversely
affected by the environment. Extreme hot and cold temperatures can damage medicines
and therefore they should be stored according to manufacturers’ recommendations, which
unless otherwise stated will be within 15oC-25oC for ambient storage or within 2oC-8oC for
fridge storage. In order to ensure the quality of medicines used within the Trust, the
temperature of all areas where medicines are stored must be monitored regularly (see point
5 for exceptions). Monitoring records may be requested in the event of an inspection. The
Trust accepts that there will occasionally be situations where the temperature deviates from
the recommended range. This SOP documents action to take in that circumstance and what
to do to mitigate risks associated with temperature excursions.
2. Purpose
The aim of this Standard Operating Procedure (SOP) is to describe the correct procedure for
monitoring the temperatures within areas of the trust where medicines are being stored.
3. Scope
This SOP applies to all appropriate staff working in areas where medicines are stored or
handled.
4. Roles and Responsibilities
It is the responsibility of individuals carrying out this procedure to:
• Have read and understood this SOP and the instructions for the temperature
monitoring equipment provided.
• Undertake the procedure as outlined below.
• Only use approved equipment – Infogrid System, EasyLog Data Loggers or Min/Max
temperature monitors – for advice on suitable equipment speak to the pharmacy
department.
• Store the temperature monitoring records where they can be retrieved for inspection.
3
In the event of a temperature excursion, see section entitled “Responding to an
alarm or temperature deviation”
5. Environmental Monitoring Procedure
Temperature recording equipment must be kept in all areas where medication is to be
stored. Exceptions to this include, but may not be exclusive to, emergency medicines
and patient own drugs. All exceptions will be documented on the Risk Register.
The Trust temperature monitoring equipment of choice is the Infogrid System platform.
This consists of temperature sensors which send readings via radio waves to a connector
device which uploads the information to the Cloud and can be viewed on the Infogrid
System website.
Other equipment is available and may be used if a need is identified after discussion with
your pharmacy lead. Any decision and reasoning for not using Infogrid System should be
documented.
EasyLog temperature data loggers record the environmental temperature on a
continuous basis; they are usually set to take a temperature reading every 10 minutes.
This data can then be downloaded onto a computer and presented as a graph showing
the recorded temperatures over a period of time. Recommended temperature data
loggers have an audible and visual alarm, indicating any temperature deviations outside
of the required boundaries. Temperature data loggers allow us to accurately see the
duration of any temperature deviations. When data loggers are used staff do not need
to use the temperature recording chart/s described below.
Min/max thermometers should have an audible alarm which alerts staff to temperature
deviations. When using min/max thermometers, staff must record the environmental
temperature on a recording chart on a daily basis (see Appendices A & B below for an
example). Staff should only use the approved OHFT chart to record temperatures.
6. Temperature monitoring
Using the Infogrid System sensors, connectors and website – you will need access to
the Infogrid System website via an individual password. Speak to your pharmacy team
if you do not have necessary access to the website.
An invitation will be sent to register on the website and create a password. Ensure that you
have actioned this email invitation.
The Infogrid System equipment will continuously record the temperature in the area they are
sited.
4
If the temperature deviates from the set range, an email will be sent to all nominated staff to
inform them that the deviation has occurred.
Log on to the Infogrid System website and select the site or ward that you want to view.
You will see what all the sensors attached to that area are recording, you can click into
individual sensors to be able to see a graph of the temperature over the time period that you
require.
The sensor that have recorded the deviation will be highlighted in the “Alerts” column.
See Appendix E for further How to Guide to Using the Infogrid System.
Using data loggers – you will need the Easy Log USB application installed on your
computer and a cable to connect the logger via USB to access the information on the
Data Logger (see Appendix C)
a) Ensure you have the EasyLog USB application on your computer and the connection
lead
b) Read the How to Guide for using the temperature data loggers (see Appendix C).
c) At the end of each month, print out a graph showing the temperatures logged during
that period.
d) At the end of each month the printed graph must be reviewed by a senior member of
the team to check if there have been any deviations, readings on the graph above or
below the set temperatures, once happy that all deviations have been reported and
actioned they MUST sign and date the graph.
e) File this graph in the Temperature Monitoring section of the Medicines Management
Folder, which should be kept in the clinic room, along with the calibration certificates
or the manual showing the accuracy specifications for the devices being used. These
records may be requested during an inspection.
f) Ensure that the data logger is set to continue monitoring by following the user guide
– see appendix C and replace in the required location.
Using Min/Max Temperature Monitors
a. Ensure that the maximum and minimum temperatures are set on the thermometer
(Fridge min 2°C / max 8°C and ambient min 15°C / max 25°C) to enable the alarm to
sound if a temperature is logged out of the range set
b. Using the OHFT Temperature Monitoring Form, at the beginning of each month start
a new recording chart (see Appendices A & B below for example). Write the month
and year in the appropriate space and circle the readings from the thermometer(s)
5
for that day, please note there are two temperature monitoring forms, one for ambient
and one for fridge.
c. Each day thereafter, check the temperature shown on the thermometer(s) and circle
max and min temperatures onto the chart. Sign in the appropriate space.
d. After recording the temperatures on the chart, reset the thermometer by pressing the
‘memory clear’ button on the front of the device – see appendix D.
e. If daily recording isn’t possible, enter the details as frequently as possible. Min/max
thermometers will keep a record of the minimum and maximum temperature reached
until it is reset.
f. During extreme (hot/cold) weather conditions the temperature should be monitored
more frequently.
g. At the end of each month the completed monitoring record form must reviewed by a
senior member of the team ward / unit to check if there have been any deviations,
once happy that all deviations have been reported and actioned they MUST sign and
date the form.
h. All records must be kept in a folder labelled ‘Medicines Management Folder’ along
with the thermometers calibration certificate. These records will be requested during
an inspection.
Responding to an Alarm or a Temperature Deviation:
a) The alarms or notifications on the temperature monitoring equipment are set to go off if
the temperature reaches the boundaries of the desired range i.e. Ambient 15°C - 25°C or
Fridge 2oC -8oC.
b) If the alarms go off or you are notified of a deviation via an email or telephone alert, action
must be taken to try to ensure that the room or fridge remains within the desired range –
open / close windows (ensure the windows are closed when leaving the clinic room), close
fridge door, contact Estates to service fridge.
c) Once these measures have been taken, record the temperatures that have been reached
and for how long the excursion lasted. For min/max thermometers this can be recorded
on the record sheet.
d) Refer to the Temperature Excursion Response Matrix in the first instance to decide what
action to take. Follow the instructions on the Matrix and be sure to document all your
actions on the event log on the Infogrid System so that an audit trail is maintained for
review by inspectors. If using min/max the actions should be documented on the
record sheets
6
e) If there is a need to inform a member of pharmacy staff or the medicines information
department, they will need to know the temperature reached and an estimate of how
long the temperature has been out of range. They will also need to know the details of all
medication stored there.
f) Any decision to reduce the expiry date of the medicines or destroy any medicines due to
temperature excursions MUST be approved by the pharmacy clinical lead for your
directorate. Stock can be quarantined but CANNOT be altered or destroyed without
appropriate permission. Even after a temperature excursion medicines may still be safe to
use and this decision lies with the pharmacy team.
Definitions
Ambient room temperature
The minimum and maximum temperatures are within range of 15oC and 25oC
Fridge temperature
The minimum and maximum temperatures are within range of 2 oC and 8 oC
Temperature deviations
Pharmacy staff, or Medicines Information, will utilise the following calculations to base their
advice regarding medicines that have been subjected to temperature deviations1;
• Q10 calculations
• Mean Kinetic Temperature
These calculations allow pharmacy to provide advice on the suitability of a medicine for
administration after temperature deviation or the need to reduce the expiry (shelf-life) of a
medicine.
Revision History
• April 2019 - This SOP has been revised to include details about using the Infogrid
System Software. The sections to do with data loggers has also been removed from
the SOP.
• December 2018 - This SOP has been revised to include details about using the DT
Solutions equipment. data loggers as well as min/max thermometers.
• May 2018 -This SOP has been reviewed to include an updated temperature
monitoring form as well as adding details of getting the Easy log software for
individual users, also a ‘how to guide’ on how to set up and download the data from
the temperature data loggers.
7
References
1NHS Pharmaceutical QA Committee (1st Edition) Risk Management of Medicines Stored in Clinical Areas: Temperature Control
Appendices
A. Fridge Temperature Monitoring Record (min / max thermometers)
B. Ambient Temperature Monitoring Record (min / max thermometers)
C. How to guide for using Data Loggers.
D. How to use the Maximum/Minimum Temperature Monitor
E. How to guide to Infogrid System Software.
F. Temperature Excursion Response Matrix
8
Appendix A: Fridge Monitoring Form
Actu
alCh
ecke
d by
Ther
mom
eter
Acti
ons
take
n if
ala
rm s
ound
s
°Cin
itia
lsRe
set (
tick
)or
tem
pera
ture
out
of r
ange
1-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
2-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
3-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
4-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
5-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
6-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
7-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
8-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
9-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
10-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
11-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
12-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
13-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
14-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
15-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
16-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
17-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
18-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
19-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
20-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
21-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
22-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
23-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
24-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
25-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
26-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
27-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
28-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
29-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
30-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
31-1
01
23
45
67
89
1011
-10
12
34
56
78
910
11
Any
devi
atio
ns
(Ple
ase
Circ
le)
All d
evia
tion
s ha
ve b
een
acti
oned
acc
ordi
ng
to th
e Te
mpe
ratu
re M
onit
orin
g SO
PYe
s /
NO
or
N/A
Chec
ked
&
sign
ed
Report to Team Leader & seek advice from Medicines Management/Pharmacy
Report to Team Leader & seek advice from Medicines Management/Pharmacy
Report to Team Leader & seek advice from Medicines Management/Pharmacy
Report to Team Leader & seek advice from Medicines Management/Pharmacy
MA
X
Dat
eYE
S /
NO
DA
ILY
MED
ICIN
ES R
EFRI
GER
ATO
R M
ON
ITO
RIN
G F
ORM
MU
ST R
EPO
RT &
ACT
ION
IF T
EMPE
RATU
RE IS
LO
WER
TH
AN 2
°C O
R H
IGH
ER T
HAN
8°C
OR
ALAR
M S
OU
ND
S
Tem
pera
ture
°C (c
ircl
e as
app
ropr
iate
)
ACT
ION
ACT
ION
ACT
ION
MO
NTH
:
YEAR
:
ACT
ION
MIN
Tim
eD
ate
9
Appendix B: Ambient Monitoring Form
Ac
tual
Checked
Actio
ns taken if
ala
rm s
ounds
°Cby
(initia
ls)
or te
mpera
ture
out o
f ra
nge
113
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
213
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
313
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
413
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
513
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
613
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
713
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
813
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
913
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1013
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1113
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1213
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1313
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1413
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1513
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1613
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1713
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1813
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
1913
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2013
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2113
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2213
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2313
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2413
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2513
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2613
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2713
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2813
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
2913
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
3013
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
3113
1415
1617
1819
2021
2223
2425
2627
2813
1415
1617
1819
2021
2223
2425
2627
28
Reset
(tic
k)
Report to Team Leader & seek advice from Medicines Management / Pharmacy
MA
XM
IN
ACT
ION
ACT
ION
All d
evia
tion
s ha
ve b
een
acti
oned
acc
ordi
ng to
the
Tem
pera
ture
Mon
itor
ing
SOP
DA
ILY
MED
ICIN
ES A
MBI
ENT
ROO
M T
EMPE
RATU
RE M
ON
ITO
RIN
G F
ORM
MU
ST R
EPO
RT &
ACT
ION
IF T
EMPE
RATU
RE IS
LO
WER
TH
AN 1
5°C
OR
HIG
HER
TH
AN 2
5°C
OR
ALAR
M S
OU
ND
S
Chec
ked
& s
igne
d
byD
ate
Any
devi
atio
ns
(Ple
ase
Circ
le)
Tem
pera
ture
°C (c
ircl
e as
app
ropr
iate
)
ACT
ION
ACT
ION
MO
NTH
:
YEAR
:
Report to Team Leader & seek advice from Medicines Management / Pharmacy
Report to Team Leader & seek advice from Medicines Management / Pharmacy
Tim
eD
ate
YES
/ N
OYe
s /
NO
or
N/A
10
Appendix C: How to guide for using Data Loggers
Downloading the software
In order to use your temperature data logger, you will need to download the EasyLog
software onto your computer. You should ensure that several members of your team have
access to this software so that the data logger can be used at all times (please note: the
software is only accessible to an individual user log in) follow the instructions below to order
the EasyLog software onto your lap/desk top computer from IT
• Intranet home page ->
• Departments ->
• IT ->
• Getting it Done ->
• Order things ->
• Log in with desktop log in /user name ->
• Software ->
• Business Applications ->
• EasyLog USB ->
• Enter computer name i.e (OXHFT – four-digit number from home page of your
desktop / laptop) If you have a problem with this click on the magnifying glass icon
this should bring the computer name up ->
• Click ‘order now’ on the right-hand side of the page
• Ensure you inform your Manager that you have ordered this for them to approve
• Once approved IT will put it on your computer / laptop – please note that this will be
for your personal log in only
Once the software is installed you will see the icon below on your
screen: if IT have said they have installed this and you can’t see it on
your device, contact IT for advice
11
Installing / setting the data logger to record
• Using the USB cable that is supplied with the temperature data logger, attach the
logger to your computer/laptop
• Open the application the following screen will appear:
The screen below will appear - Follow steps 1 to 4
Easy Log
Temperature
Data Logger
USB Cable to
attach the
temperature
logger to your
desk/lap top
Click on ‘Set
up and start
the USB data
logger’
1, Enter the Ward /
Unit Name & indicate
if fridge or ambient
(i.e. Bluebell Fridge)
2. Ensure the
Temperature scale is
set to °C
3. Set the frequency of log to
10 mins / 2 years
4. Click ‘Next’
12
The screen below will then appear: Follow the steps
Setting the Temperature
Ambient temperature the max (high alarm) is 25°C and the min (low alarm) is 15°C.
Fridge monitoring the max (high alarm) is 8°C and the min (low alarm) is 2°C.
Follow the instructions below:
1. Select ‘LCD & backlight on for a short period after
button pressed’
2. Ensure this
box is NOT
ticked – as we
don’t want the
logger to stop
recording 3. Click
‘Next’
1. Tick BOTH ‘high alarm’
& ‘low Alarm’
2. Enter the high &
low temperature
range for either ambient or fridge
3. Tick BOTH ‘hold’
boxes
4. Click ‘Next’
13
Setting the Alarm on the logger
Setting the logger to Start
On the final page you can choose when you want the logger to start logging. This is useful if
you are programming it in a separate location to where it will be used, and you therefore
wish to delay the start – select the option you would like
• The screen on the temperature logger will light up once set.
• The following screen will be displayed on your computer
1. Enter ‘1’
2. Ensure that the
‘Disable all LEDs’ &
‘Disable sounder’ are
NOT ticked
3. Click ‘Next’
1. Select when you
want the
temperature data
logger to start
recording the
temperature
2. Click ‘Finish’
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Once programmed you can remove the USB connection (store in a safe place) and place the
data logger in the desired location – ensuring you put them in the temperature that the data
logger is set for
Maintenance of the temperature data logger
Once the Temperature data logger is in place, by pressing the button on the RIGHT you can
• Check what the current temperature is in the room / fridge by pressing the button on
the right
• Check that the batteries in the log aren’t running low
To view the temperature,
press the button on the
Right, this will also show if
the batteries are running low
Click ‘OK’
15
Appendix D: How to use the Maximum/Minimum Temperature
Monitor
• Set up the thermometer
as per the manufacturer’s
instructions
• Every day -take the max /
min temp
• Record on the
appropriate monitoring
sheet
• Press the ‘memory clear’
button to reset the
monitor
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Appendix E: How to Guide Infogrid System Software
• Note: The Infogrid system only works on Google Chrome web browser.
Google Chrome can be requested from IT using the link below;
https://oxfordhealth.service-now.com/oxford_health_ess/business_applications.do
• Access the Infogrid webpage https://app.infogrid.io
• If you do not have a password to access the system, please speak to your pharmacy
team.
• Enter your email and password where indicated.
• The sites or wards allocated to you will be listed.
• Click onto an individual ward or unit to view the information about that site.
• On the individual site page, you can see a list of sensors for the ward / unit and the
temperature that they have most recently recorded.
• To review a particular area (e.g. fridge) where perhaps there has been a deviation,
click on the relevant sensor name to see the information and a graph. The “Historical
data” tabs will allow you to view the last hour, last day, last week or last month. You
may also customise the data range you wish to view.
• If there has been a temperature deviation this will create an alert. The un-actioned
alerts will be highlighted in red on this page.
• Click on “View event log” to see details of the deviation(s).
• Refer back to the relevant period on the historical graph to ascertain the extent and
duration of the deviation.
• Use the information on the Temperature Excursion Response Matrix to aid a decision
on your actions following the excursion.
• To acknowledge single or multiple alert(s):
o Single alert – Click on View Event Log and click the green acknowledge button
and add any text to reflect your actions regarding this temperature excursion.
o Multiple alerts – Click on Acknowledge all and add any text to reflect your
actions regarding these temperature excursions.
• On the Event Log you can use the message tab at the bottom to enter any relevant
text as a separate line from acknowledgements.
• All temperature graphs and logs can be downloaded to save or print
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Appendix F: Temperature Excursion Response Matrix
All medicines in the fridge should be stored between 2 and 8˚C
All other medicines should be stored between 15 and 25˚C
Temp/Time Anything up to 30
minutes
BRIEF
Up to 1 hour
MODERATE
1-4 hours
EXTENDED
4 hours plus
Fridge out of
temperature
range (below 2˚C
or above 8˚C)
All fridge deviations that exceed 30 minutes should be communicated to the pharmacy team as soon as possible but no later than the next day.
If there is no response within 24 hours, contact pharmacy (01865 904888) or Medicines Information for advice (01865 904365).
Ambient Storage
has been recorded
up to 29˚C
No Action needed Document excursion on the on the
Infogrid event log
Follow guidance on SOP. Email your
pharmacist or MMT (see overleaf). Document
action on the Infogrid event log. A response
should be expected by the end of the next
working day.
Follow guidance on SOP. Email your pharmacist
or MMT (see overleaf). Document action on the
Infogrid event log. A response should be
expected by the end of the next working day.
Ambient storage
recorded as
between 29-35˚C
Document
excursion on the on
the Infogrid event
log
Document excursion on the Infogrid
Event Log. No further action needed if
temperature has returned to normal
range.
Follow guidance on SOP. Email your
pharmacist or MMT (see overleaf). Document
action on the Infogrid event log. A response
should be expected by the end of the next
working day.
Contact your pharmacist or MMT as a matter of
urgency. If no response is received by the
following day, contact pharmacy or medicines
information. Document action on temperature
excursion form/ event log.
Ambient storage
recorded as over
35˚C
Document
excursion on the on
the Infogrid event
log
Follow guidance on SOP. Email your
pharmacist or MMT (see overleaf).
Document action on the Infogrid event
log. A response should be expected by
the end of the next working day.
Follow guidance on SOP. Email ward
pharmacist or MMT (see overleaf). Document
action on the Infogrid event log. A response
should be expected by the end of the next
working day.
Contact your pharmacist or MMT as a matter of
urgency. If no response is received by the
following day, contact pharmacy or medicines
information. Document action on temperature
excursion form/ event log.
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Information to gather before calling medicines information, pharmacy or ward pharmacist/MMT:
• What is the highest/lowest temperature reached during the time it has been out of range?
• How long has the temperature been outside of the recommended range?
• What action has already been taken?
• Do you have any medicines stored in your department with special storage requirements?
Contacts:
Ward/Unit Pharmacist:
Tel/Email:
Ward/Unit Medicines Management Technician:
Tel/Email:
CPSU Pharmacy: 01865 904888 / [email protected]
Weston Pharmacy: 01865 903843 / [email protected]
Medicines Information: 01865 904365 / [email protected]
Suggested email template to be sent following temperature excursion:
Dear
The temperature on ***** ward/unit has deviated from the recommended storage range. The fridge/ambient temperature has been recorded as … for … hours.
Please respond with any necessary action.
