Standard operating procedure

Vaccine & Cold Chain Management Procedure

Storing, monitoring and handling vaccines to maintain an unbroken cold chain at 2 to 8 degrees Celsius in UK general practice.

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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Equipment and materials
  • 6. Procedure
  • 7. Documentation
  • 8. Records
  • 9. Related documents
  • 10. Review and version control
  • 11. Disclaimer

Legislation & standards it maps to

  • UK Health Security Agency (UKHSA), Immunisation against infectious disease (the Green Book), Chapter 3: Storage, distribution and disposal of vaccines
  • Human Medicines Regulations 2012
  • Medicines and Healthcare products Regulatory Agency (MHRA) guidance on the control and monitoring of storage temperatures for medicinal products
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (Safe care and treatment)

Who it applies to

All staff at [Organisation Name] who order, receive, store, monitor or administer vaccines, including practice nurses, healthcare assistants, the nominated vaccine lead and reception staff who accept deliveries.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Anaphylaxis
A severe, life-threatening allergic reaction needing immediate emergency treatment.
Calibration
Checking and adjusting a thermometer or other instrument against a known standard so its readings can be trusted.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Cold chain
Keeping vaccines and certain medicines within a safe temperature range, here 2 to 8 degrees Celsius, from delivery through to use.
Cold-chain indicator
A small device or label included with a delivery that changes to show whether the vaccines have been exposed to an unsafe temperature in transit.
Contemporaneous
Written down at the time the event happened, rather than from memory later.
Contingency plan
A prepared set of actions to follow if something goes wrong, such as the refrigerator failing or losing power.
Data logger
An electronic device that continuously records a refrigerator's temperature and can sound an alarm or report when the temperature goes out of range.
Green Book (Immunisation against infectious disease)
The UK Health Security Agency's official guidance on vaccines and how to store, handle and give them.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting out the fundamental standards that registered health and care providers must meet, enforced by the Care Quality Commission.
Health Protection Team (HPT)
A local team, linked to the UK Health Security Agency, that gives advice on controlling infection and on incidents such as vaccine temperature excursions.
Human Medicines Regulations 2012
The main UK law governing how medicines, including vaccines, are authorised, supplied, stored and handled.
Max/min thermometer
A thermometer that shows the current temperature plus the highest and lowest temperatures reached since it was last reset.
Medicines and Healthcare products Regulatory Agency (MHRA)
The body that regulates medicines and medical devices in the United Kingdom and sets expectations for storing them safely.
Pharmaceutical refrigerator
A refrigerator built specially to hold medicines and vaccines at a steady, even temperature, unlike an ordinary domestic fridge.
Potency
How strong and effective a vaccine is; potency is lost if the vaccine is stored at the wrong temperature.
Quarantine
Setting aside and clearly labelling stock so it is not used until a decision has been made about whether it is safe.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Regulation 12 (Safe care and treatment)
The part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 that requires care and treatment, including medicines storage, to be provided safely.
Screening and Immunisation Team (SIT)
A local team responsible for overseeing vaccination and screening programmes and advising practices on vaccine supply and incidents.
Standard Operating Procedure (SOP)
A written, step-by-step instruction setting out how a particular task must be carried out consistently and safely.
Stock rotation (first expired, first out)
Arranging and using stock so that items with the earliest expiry date are used before newer ones, to reduce waste.
Temperature excursion
Any recorded temperature outside the safe 2 to 8 degrees Celsius range, or any period when the temperature is unknown, for example after a power loss.
UK Health Security Agency (UKHSA)
The national public health agency for the United Kingdom, which publishes the Green Book and advises on protecting people from infectious disease.
Vaccine lead
The named member of staff with day-to-day responsibility for ordering, storing and monitoring vaccines and acting on any cold-chain problem.
Validated transport container
A cool box or carrier proven to keep vaccines within the safe temperature range while they are moved.

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