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TJC Compliance Study Takes A Closer Look At Hospital Refrigeration

Mar 14, 2014

Hospital uncovers problems with patient care refrigerators during WTM evaluation..

As discussed in the first piece in this series, The Joint Commission is a member based organization that develops standards and best practices in partnership with its healthcare member organizations such as hospitals, medical practices and pharmacies insure their patients and clients receive safe, effective quality care. The series is prompted by a piece on the Pharmacy Purchasing & Products website describing the use of Wireless Temperature Monitoring (WTM) systems to monitor medication refrigeration. (Link to PPP Article)

A closer look at the Medication Monitoring chapter in one of TJC’s documents describing Medication Management in Hospitals (Link to TJC Document) finds several areas that address temperature monitoring in refrigeration used to store medication.

A search of TJC’s website’s Standards FAQ (Link to TJC FAQ) for Medication Management (CAMH/Hospitals) finds the following regarding Medication Refrigeration Temperature Logs.

FAQ: Medication Refrigeration Temperature Logs    

Updated | November 24, 2008

Q:  Are we required to maintain temperature logs for medication storage refrigerators and freezers?    

A:  Joint Commission does not specifically require temperature logs for refrigerators and freezers used for medication storage. Standard MM.03.01.01, EP2 requires that medications be stored according to manufacturer's recommendations. Additionally, EC. 01.01.01 requires that organization describes and implement processes to maintain and monitor equipment performance. If your organization chooses to use temperature monitoring to achieve this, the monitoring method must track temperature in an ongoing fashion to indicate whether or not internal temperature has deviated from the required ranges for all drugs stored. In addition, the organization should have a defined process outlining disposition of medication from a refrigerator or freezer which has deviated from the recommended temperature range.

While organizations are not specifically required to refrigerator temperature logs, there is a requirement to store them in accordance with manufacturer’s recommendations. As the FAQ notes, other chapters refer to ensuring equipment is operational and maintained. Taken in the whole, monitoring of medication temperatures can meet these requirements. And while manual monitoring and recording temperatures is one way to meet this requirement, in many cases hospital staff duties as well as day to day challenges can lead to gaps in the data on days where time normally allocated for manual monitoring is used for more urgent needs.

New York Hospital Queens is the site of the WTM study (Link to Source)

The Pharmacy Purchasing & Products website piece describes a study by a 540-bed hospital in New York City wherein a mock accreditation was conducted. The author noted the “mock surveys identified that our method of manually documenting temperatures in refrigerators and freezers storing medication, nutrition products and blood products was insufficient and created the risk of a potential regulatory citation.”

This is not an uncommon experience in medicine storage applications. The lack of a robust review of current practices can often lead to the uncovering of flaws when dedicated resources are used to examine these practices and compare them to industry best practices. However, factors such as the suitability of hospital, pharmacy or medical office equipment and infrastructure to meet and maintain regulatory guidelines can also come into play and may want to be examined before implementing robust monitoring technologies.

To that end, prior to committing hospital personnel and financial resources to a WTM system an audit of the ability of the existing refrigerators was undertaken and found that many of the units in patient care areas were small household units not capable of maintaining temperatures within required ranges for medication, blood and nutrition products. The hospital replaced these units with medical grade, under the counter, programmable refrigerators before undertaking an evaluation of Wireless Temperature Monitoring systems.

Dorm grade compact refrigerator (left) costs around $250 (Link to Source) compared to hospital grade compact refrigerator (right) that can cost $600, $900 or more (Link to Source). Hospitals using non-medical grade refrigeration will be well served by monitoring performance over time and during different parts of the day and usage to determine if the device can maintain medicines, blood and other products used in patient treatment at recommended temperatures to assure efficacy and safety.

The next piece in this series will examine the WTM evaluation experience including technology and configuration options and installation considerations. Future pieces will focus on technical and practical information regarding temperature sensitive medicines storage best practices, monitoring technologies and implementation strategies that include both wireless and wired, fault tolerant and cloud based solutions to provide a complete picture of options available and associated costs and benefits.

Temperature@ert’s WiFi, Cellular and ZPoint product offerings linked to the company’s Sensor Cloud platform provides a cost effective solution for organizations of all sizes. The products and services can help bring a laboratory or medical practice into compliance with minimum training or effort. For information about Temperature@lert’s Cellular and Sensor Cloud offerings, visit our website at or call us at +1-866-524-3540.

Written By:

Dave Ruede, Well-Versed Wordsmith

Dave Ruede, a dyed in the wool Connecticut Yankee, has been involved with high tech companies for the past three decades. His background in chemistry and experience in a multitude of industries such as industrial chemicals and systems, pulp and paper, semiconductor fabrication, data centers, and test and assembly facilities informs his work daily. Well-versed in sales, marketing, management, and business development, Dave brings real world experience to Temperature@lert. When not crafting new Temperature@lert projects, Dave enjoys spending time with his young granddaughter, who keeps him grounded to the simple joys in life. Such joys for this wordsmith include reading prize winning fiction and non-fiction. Although a Connecticut Yankee, living for a decade in coastal California’s not too hot, not too cold climate epitomizes Dave’s favorite temperature, 75°F.

Temperature@lert Dave Ruede

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