New guidance, produced by the National Patient Safety Agency (NPSA) and frontline services across England and Wales, has been published aimed at ensuring clinicians store vaccines at the recommended manufacturer temperature range.
The Rapid Response Report issued to all NHS acute and community organisations, as well as the independent sector, follows details received by the NPSA of 260 reported patient safety incidents between 1 January 2005 and 1 April 2009 of incorrect vaccine storage. During this time, 50 million doses of childhood vaccines were distributed across the UK. Issues included a delay in storage of vaccines, storage at wrong temperature range, fridge switched off or broken, as well as no temperature monitoring. It is not known if any of these incidents led to significant harm to the patient. The report calls on frontline services to ensure that all departments and providers (including independent contractors) have been issued with guidance relating to vaccine cold chain storage and procedures are in place to ensure correct working practices are being followed. This would include reviewing refrigerator temperature at regular intervals which would highlight if vaccines had been stored outside manufacturers’ recommended temperature ranges, before they are given to patients. Policies should also be in place for remedial action where vaccines are stored outside manufacturers’ recommended temperature ranges. The report follows the NPSA being alerted to a safety incident that showed childhood vaccines had been stored incorrectly, potentially resulting in reduced efficiency of some vaccines. Subsequent local audit showed that this may not have been an isolated incident.
