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THE UNIVERSITY OF CONNECTICUT HEALTH CENTER JOHN DEMPSEY HOSPITAL ADMINISTRATIVE MANUAL

SECTION: SUBJECT:

QUALITY MANAGEMENT MANAGEMENT OF THE UNIT MEDICATION REFRIGERATOR

NUMBER: 11 -040 PAGE: 1 of 2

POLICY: 1. Medications ("Drugs and biologicals") shall be stored under proper conditions of security, segregation, and environmental control at all storage locations. (Public Health Code Section 19 ­ 13 ­ Dv c.) Drugs shall be accessible only to legally authorized persons and shall be kept in locked storage at anytime such a legally authorized person is not in immediate attendance. All drugs requiring refrigeration shall be stored separately in a refrigerator that is locked or in a locked room and that is used exclusively for medications and medication adjuncts. There will not be any food stored in the medication refrigerator. The inside temperature of a refrigerator in which drugs are stored shall be. Maintained within a thirty ­ six degree (36) to forty ­ six degree (46) Fahrenheit or 2 -8 celsius range. Points of Emphasis: 1. The thermometer inside the refrigerator must be easily visible. A documented log of daily refrigerator temperature and date shall be maintained by appropriately designated unit staff. This log will be kept for one year and then destroyed per the State. (Please see appendix a)

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Action: 1. No less than every 24 hour period the temperature of the unit Medication Refrigerator will be checked by authorized unit staff.

THE UNIVERSITY OF CONNECTICUT HEALTH CENTER JOHN DEMPSEY HOSPITAL ADMINISTRATIVE MANUAL

SECTION: SUBJECT:

QUALITY MANAGEMENT MANAGEMENT OF THE UNIT MEDICATION REFRIGERATOR

NUMBER: 11 -040 PAGE: 2 of 2

2. If the refrigerator temperature falls out of acceptable range of 36 - 46 Fahrenheit or 2-8 celsius, a call must be placed to Facilities x2125 for repair and to pharmacy for the disposition of medications.

2.Refrigerator will remain unusable until Facilities approves use.

Medications are rendered unusable until approved by Pharmacy. Follow-up actions must be documented on the Daily Temperature Log.

3. All drugs requiring refrigeration are to be stored in a refrigerator used exclusively for medication.

3.There will not be anything other than medication stored in medication refrigerators. If food items such as apple sauce are used to administer medications they are to be stored in the patient nourishment refrigerator.

_______________________ Mike H. Summerer, M.D. Hospital Director Date Issued: July 2000 Date Revised: 10/03, 8/09 Date Reviewed: 8/05

_____________________ Richard H. Simon, M.D. Chief of Staff

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Section: Quality Management

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