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Are Your Freezer/Refrigerator Logs Giving You Frostbite?

Ensuring that you store medications, food items, lab specimens, blood, and other items and supplies at appropriate temperatures in cold storage is essential to ensure your patients receive safe and effective product. However, maintaining a record of these temperature measurements seem to confound a lot of organizations out there. We frequently observe incomplete refrigerator/freezer logs at organizations. This will bring you unwanted attention from the survey team but, most importantly, put your patients at risk if they receive an item that is ineffective, or worse, dangerous because you did not maintain proper temperatures. Here are some key tips and tricks to ensure you are staying on top of your cold storage temperature logs:

Tips and Tricks:

• Ensure your temperature logs have the designated ranges for storage. These ranges should be based on the stored products’ manufacturer instruction for use.

• Have the process posted (near the cold storage unit or on the log sheet) of actions needed to be performed in the event of a temperature excursion. Temperature excursions are when the temperature is outside of the acceptable range.

• If your actions include adjusting the temperature control, ensure you indicate when a re-measure should occur after adjustment. This should be based on the manufacturer’s instruction for use for the refrigerator/freezer. ***Important: Make sure you document on the log what the new temperature reading is after adjustment.***

• Ensure you have your action sequence to follow if the adjusted temperature cannot be achieved in a designated time posted on the log or near the cold storage. This may include moving product to another cold storage location that can maintain product at the appropriate temperature. Indicate the location for the backup storage if that is part of your action plan.

• Ensure staff are trained in the temperature monitoring process including any action steps to be taken with temperature excursions.

• Ensure your log entries are being made as required. If you are required to maintain temperatures on weekends and holidays, have a process where these actions can be completed and documented. Consider the use of digital monitoring with the ability to review historical measurements if you are unable to perform required checks in person. These measurements should be documented.

• Completed freezer/refrigerator logs should be filed and kept according to your hospital document archival policy. You should also refer to the respective governing organization for vaccine, lab and food temperature log archival regulations. This may be a local, state or federal agency.

• Leadership should be rounding for documentation compliance.

Maintaining complete records of your temperature monitoring practice is an easy way to ensure you can demonstrate that you keep your patients safe with respect to cold storage. Take time to review your practice to determine if your organization has gaps in compliance.

Christopher Pratt, MS, BSN, HACP

Author Christopher Pratt, MS, BSN, HACP

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