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CLINICAL POLICY
Management of the Unit Medication Refrigerator
A. EFFECTIVE DATE :
April 7, 2021
B. PURPOSE :
All unit medication refrigerators will be managed and maintained according the procedure outlined below to ensure
security, segregation, and environmental control at all storage locations and adhere to Public Health Code Section 19
– 13 – Dv. c.
C. 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.)
2. 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.
3. 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.
4. The inside temperature of a refrigerator in which drugs are stored shall be maintained within a 2° to 8°
Celsius range (or 36° to 46° Fahrenheit range).
5. John Dempsey Hospital (JDH) locations shall provide emergency backup power for essential dispensing
systems including unit medication refrigerators as defined by the hospital. In the event of system or
power failure please reference Emergency Backup Procedures located in Pharmacy Operational Policy,
Automated Dispensing System (Pyxis Medstation ES).
6. Only medication can be stored in unit medication refrigerators. If food items, such as applesauce, are
used to administer medications, they are to be stored in the patient nourishment refrigerator.
D. SCOPE :
This policy applies to all John Dempsey Hospital Inpatient, ED, Perioperative, and Ambulatory Procedure locations
with a Unit Medication Refrigerator
E. DEFINITIONS :
None
F. MATERIALS NEEDED :
• Thermometer inside refrigerator
• Unit-Specific Daily Refrigerator Temperature Log (for units without automated temperature sensors)
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G. PROCEDURE :
1. Centrally Monitored Units - Units with automated temperature sensors:
i. Ambient temperatures will be alarmed and recorded continuously by the centralized Stanley
electronic monitoring system. Temperature history and trends can be retrieved when needed for
troubleshooting or reviewing shelf life of refrigerated products.
ii. If the refrigerator temperature falls out of the acceptable range of 2° to 8° Celsius (or 36° to 46°
Fahrenheit) an alarm will ring at the Switchboard and ECC console. ECC will review the alarm and if
the temperature is trending out of range will call Pharmacy IT and clinical staff in the location where
the medications are stored. Pharmacy IT should be contacted by calling x4400 and asking to be
connected to Pharmacy IT on-call personnel.
a. Refrigerator will remain unusable until Facilities approves use.
b. Medications are recovered and rendered unusable until approved by Pharmacy
c. Follow-up action(s) for event and corrective action will be recorded in ECC shift log
book and documented via FAMIS work order if applicable.
2. Locally Monitored Units - Units without automated temperature sensors:
iii. Manual documentation of temperature check to be performed no less than every 24 hour period.
The temperature of the unit’s medication refrigerator will be checked by authorized unit staff.
iv. The thermometer inside the refrigerator must be easily visible.
v. A documented log of daily refrigerator temperature and date shall be maintained by appropriately
designated unit staff. This daily temperature log will be kept for a year, then destroyed per the
State.
a. See Appendix A: Temperature log
vi. If the refrigerator temperature falls out of the acceptable range of 2° to 8° Celsius (or 36° to 46°
Fahrenheit), a call must be placed to Facilities x2125 for repair, Pharmacy IT and to staff in the
location where the medications are stored. Pharmacy IT should be contacted by calling x4400 and
asking to be connected to IT on-call personnel.
a. Refrigerator will remain unusable until Facilities approves use.
b. Medications are recovered and rendered unusable until approved by Pharmacy
c. Follow-up action(s) for event and corrective action will be documented on the Daily
Temperature log and via FAMIS work order if applicable.
H. ATTACHMENTS :
Appendix A: Temperature Log
I. REFERENCES :
Public Health Code Section 19 – 13 – Dv. c.
J. SEARCH WORDS :
Medication, Temperature, Refrigerator, Log
K. ENFORCEMENT :
Violations of this policy or associated procedures may result in appropriate disciplinary measures in accordance with
University By-Laws, General Rules of Conduct for All University Employees, applicable collective bargaining
agreements, the University of Connecticut Student Code, other applicable University Policies, or as outlined in any
procedures document related to this policy.
L. STAKEHOLDER:
On File
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M. COMMITTEE APPROVALS:
None
N. FINAL APPROVALS:
1. Andrew Agwunobi, MD (Signed 04/13/2021
Andrew Agwunobi, MD, MBA Date
UConn Health Chief Executive Officer
2. Anne Horbatuck (Signed) 04/07/2021
Anne D. Horbatuck, RN, BSN, MBA Date
Clinical Policy Committee Co-Chair
3. Scott Allen, MD (Signed) 04/09/2021
Scott Allen, MD Date
Clinical Policy Committee Co-Chair
4. Caryl Ryan (Signed) 04/08/2021
Caryl Ryan, MS, BSN, RN Date
VP Quality and Patient Services & Chief Nursing Officer
O. REVISION HISTORY:
Date Issued: 7/00
Date Revised: 10/03, 8/05, 8/09, 1/16, 4/16
Date Reviewed: 4/21
